What is the optimal caesarean section rate? An outcome based study of existing variation.

Joffe, Michael; Chapple, Jean; Paterson, Catherine M.; Beard, R. W.

doi:10.1136/jech.48.4.406

Cited by 38 publications

(30 citation statements)

References 19 publications

(13 reference statements)

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“…It has been suggested that non‐medical factors, such as social, cultural, or unequal accessibility to health services, as well as clinical practice patterns/styles, might have been major contributors to the wide variation in caesarean section rates across different countries 1, 2, 6, 7, 8, 9, 10. On the other hand, we can presume that the rates of medically necessary caesarean section associated with the lowest maternal and neonatal mortality should vary less among countries, if the same indications for caesarean section had been applied across all nations 4, 11. What, then, should be the appropriate caesarean section rate?…”

Section: Introductionmentioning

confidence: 99%

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data

Zhang

Mikolajczyk

et al. 2015

BJOG

317

277

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ObjectiveCaesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality.DesignEcological study using longitudinal data.SettingWorldwide country‐level data.PopulationA total of 159 countries were included in the analyses, representing 98.0% of global live births (2005).MethodsNationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio‐economic development by means of human development index (HDI) using fractional polynomial regression models.Main outcome measuresMaternal mortality ratio and neonatal mortality rate.ResultsMost countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5–10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%.ConclusionsAlthough caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality.Tweetable abstractThe caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality.

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Section: Introductionmentioning

confidence: 99%

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data

Zhang

Mikolajczyk

et al. 2015

BJOG

317

277

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“…However, there is limited research on the possible relation between hospital obstetric (particularly intrapartum) practice and extended perinatal outcomes. [3][4][5][6][7][8][9] More is known about the links between paediatric neonatal care and mortality. These studies suggest that infants from high risk and low birthweight births are less likely to die if born in more specialised units and that in utero transfers are safer than ex utero.…”

mentioning

confidence: 99%

Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality

Joyce

2004

Archives of Disease in Childhood - Fetal and Neonatal Edition

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Background: Previous studies suggest that high risk and low birthweight babies have better outcomes if born in hospitals with level III neonatal intensive care units. Relations between obstetric care, particularly intrapartum interventions and perinatal outcomes, are less well understood, however. Objective: To investigate effects of obstetric, paediatric, and demographic factors on rates of hospital stillbirths and neonatal mortality. Methods: Cross sectional data on all 65 maternity units in all Thames Regions, 1994Regions, -1996, covering 540 834 live births and stillbirths. Hospital level analyses investigated associations between staffing rates (consultant/junior paediatricians, consultant/junior obstetricians, midwives), facilities (consultant obstetrician/anaesthetist sessions, delivery beds, special care baby unit, neonatal intensive care unit cots, etc), interventions (vaginal births, caesarean sections, forceps, epidurals, inductions, general anaesthetic), parental data (parity, maternal age, social class, deprivation, multiple births), and birthweight standardised stillbirth rates and neonatal mortality. Results: Unifactorial analyses showed consistent negative associations between measures of obstetric intervention and stillbirth rates. Some measures of staffing, facilities, and parental data also showed significant associations. Scores for interventional, organisational, and parental variables were derived for multifactorial analysis to overcome the statistical problems caused by high intercorrelations between variables. A higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates. Organisational and parental factors were not significant after adjustment. Only Townsend deprivation score was significantly associated with neonatal mortality (positive correlation). Conclusions: Birthweight adjusted stillbirth rates were significantly lower in units that took a more interventionalist approach and in those with higher levels of consultant obstetric staffing. There were no apparent associations between neonatal death rates and the hospital factors measured here.

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“…An analysis of pregnancies in one English health region compared groups of obstetric units, categorised according to their caesarean section rates, to see what effect the rate had on a range of outcome variables 5. Care was taken to avoid confounding and selection effects.…”

mentioning

confidence: 99%

Variation in caesarean section rates What difference does it make?

Joffe¹

1994

BMJ

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What is the optimal caesarean section rate? An outcome based study of existing variation.

Abstract: Study objective -To investigate the consequences of different levels of caesarean section (CS)

Cited by 38 publications

References 19 publications

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data

Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality

Variation in caesarean section rates What difference does it make?

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