Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries

Exploring the influence of medical staffing and birth volume on observed-to-expected cesarean deliveries: a panel data analysis of integrated obstetric and gynecological departments in Germany

INTRODUCTION

Cesarean deliveries account for approximately one-third of all births in Germany, prompting ongoing discussions on cesarean section rates and their connection to medical staffing and birth volume. In Germany, the majority of departments integrate obstetric and gynecological care within a single department.

METHODS

The analysis utilized quality reports from German hospitals spanning 2015 to 2019. The outcome variable was the annual risk-adjusted cesarean section ratio-a metric comparing expected to observed cesarean sections. Explanatory variables included annual counts of physicians, midwives, and births. To account for case number-related staffing variations, full-time equivalent midwife and physician staff positions were normalized by the number of deliveries. Uni- and multivariate panel models were applied, complemented by multiple instrument variable analyses, including two-stage least square and generalized method of moments models.

RESULTS

Incorporating data from 509 integrated obstetric departments and 2089 observations, representing 2,335,839 deliveries with 720,795 cesarean sections (over 60% of all inpatient births in Germany), multivariate model with fixed effects revealed a statistically significant positive association between the number of physicians per birth and the risk-adjusted cesarean section ratio (0.004, p = 0.004). Two-stage least square instrument variable analysis (0.020, p < 0.001) and a system GMM estimator models (0.004, p < 0.001) validated these results, providing compelling evidence for a causal relationship.

CONCLUSION

The study established a robust connection between the number of physicians per birth and the risk-adjusted cesarean section ratio in integrated obstetric and gynecological departments in Germany. While the cause of the effect remains unclear, one possible explanation is a lack of specialization within these departments due to the combined provision of both obstetric and gynecological care.

The influence of emotional labor and emotional intelligence on cesarean section decision-making among midwives and obstetricians in Kosovo: A cross-sectional study using conjoint analysis

INTRODUCTION

Cesarean section rates continue to increase worldwide. In 2021, one in every five deliveries was delivered by cesarean section. This is particularly alarming in resource-limited countries such as Kosovo, where the rates continue to increase and vary considerably between hospitals. Understanding the underlying factors that drive the increase and variation of cesarean section rates may help to change these trends. This study investigates how emotional intelligence and emotional labor impact cesarean section decision-making among midwives and obstetricians in Kosovo, along with clinical factors.

METHODS

We employed a conjoint analysis using a cross-sectional study design to assess preferences that drive decisions for cesarean section. We used the Dutch questionnaire on Emotional Labor, the Assessing Emotions Scale, and the Quality of Decision-making questionnaire, and designed a conjoint questionnaire with 28 hypothetical scenarios. We invited all midwives and obstetricians employed at the Gynecology and Obstetrics Clinic of the University Clinical Centre of Kosovo to participate in the study. The data were collected from January to the end of March 2023. Stata 18 BE was used for statistical computing and data visualization.

RESULTS

A gestational age of 42 weeks decreased CS likelihood among midwives (OR=0.75; 95% CI: 0.62-0.90, p=0.002). Previous cesarean sections (OR=1.42; 95% CI: 1.11-1.81, p=0.005) and hypertension (OR=1.23; 95% CI: 1.01-1.51, p=0.042) raised CS odds for midwives. A pelvic size of 8 cm significantly increased CS likelihood for midwives (OR=1.70; 95% CI: 1.37-2.09, p<0.001), while a size of 11 cm was protective for both groups (midwives: OR=0.73; 95% CI: 0.57-0.93, p=0.010; obstetricians: OR=0.70; 95% CI: 0.52-0.94, p=0.019). Maternal age of 40 years was significant only for obstetricians (OR=1.43; 95% CI: 1.00-2.06, p=0.052), and university education was significant for midwives (OR=1.19; 95% CI: 1.03-1.37, p=0.020). Non-clinical factors and emotional measures showed no significant or consistent trends in either group.

CONCLUSIONS

Various clinical and non-clinical factors shape the decision to recommend a cesarean section, with obstetricians and midwives prioritizing these factors differently. These findings underscore the importance of implementing evidence-based practices to enhance maternal and newborn health outcomes in Kosovo and similar settings, while optimizing cesarean decision-making.

How cesarean section rates can be reduced through an effective financial strategy: A protocol for systematic review

BACKGROUND

The incidence of cesarean section (c-section) has been increasing after the introduction of national health coverage. There is potential evidence that unnecessary c-sections can be reduced through an effective financial strategy, which would make it possible to increase health equity in the future. Consistent with global trends, the rate of c-section in Indonesia increased from 1.6% in 1991 to 17.6% in 2017, while the World Health Organization standard rate is 10% to 15%. This study aims to explore and analyze strategies to reduce c-section rates and to report evidence-based research on an effective financial strategy model for reducing these rates.

METHODS

We used a systematic review framework involving electronic databases including PubMed, ProQuest, and ScienceDirect. The following literature search terms were used: "cost-benefit analysis," "universal health care," "cost controls," "health expenditures," "out-of-pocket expenses," "c-section," and "abdominal delivery." The Joanna Briggs Institute critical appraisal checklist was used to independently assess the methodological quality. The findings were compiled using a meta-aggregation approach to summarize quantitative analysis results potentially based on different methodologies.

RESULTS

Among 883 database records, 26 studies were retained for full-text review. C-section risk factors, the role of financial system evaluation, and the application of the clinical audit cycles with assessments using Robson classification were discussed in the included papers. Several studies highlighted the crucial function of evaluating reward reimbursement schemes, suggesting that decreased c-section rates and other maternal-neonatal outcomes should be used as indicators.

DISCUSSION

This study identified an evidence base that suggests using Robson classification in clinical audit cycles to reduce c-section rates and avoid unnecessary c-sections. The other proposals for decreasing the rate were mainly focused on financial and nonfinancial strategies applied nationally and locally in hospital settings.

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

Staff Resources in Public and Private Hospitals and Their Implication for Medical Practice: A French Study of Caesareans

This study aimed to investigate the effect of hospital staffing resources on medical practice in public versus private hospitals. We used exhaustive delivery data from a French district of 11 hospitals over an 11-year period, from 2008 to 2018, including 168,120 observations. We performed multilevel logistic regression models with hospital fixed or random effects, while controlling for factors known to influence obstetric practice. We found that hospital staff ratios of obstetricians and that of midwives affected caesarean rates, but with different effects depending on the hospital sector. In public hospitals, the higher the ratio of obstetricians and that of midwives, the lower the probability of planned caesareans. In private hospitals, the higher the ratio of obstetricians, the greater the probability of planned caesareans. Indeed, in public hospitals, obstetricians and midwives, both salaried employees, do not have financial or organizational incentives to perform more caesareans. In private hospitals, obstetricians, who are independent doctors, may have such incentives. Our results underline the importance of having an adequate supply of health professionals in healthcare facilities to ensure appropriate care, with specific regard to the different characteristics of the public and private sectors.

Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting

BACKGROUND

Pregnancy is a high-risk time for patients with Marfan syndrome or Loeys-Dietz syndrome because of the risk for cardiovascular complications, including the risk for aortic dissection. Little is known about the differences in obstetrical and cardiac outcomes based on delivery hospital setting (academic or academic-affiliated vs community medical centers).

OBJECTIVE

This study aimed to evaluate the obstetrical and cardiac outcomes of patients with Marfan syndrome or Loeys-Dietz syndrome based on delivery hospital setting.

STUDY DESIGN

This was a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of Marfan syndrome or Loeys-Dietz syndrome from 1990 to 2016. Patients were identified through the Marfan Foundation, the Loeys-Dietz Syndrome Foundation, or the Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetrical history and verified by review of medical records. Nonparametric analyses were performed using Fisher's exact tests and Wilcoxon rank-sum tests.

RESULTS

A total of 273 deliveries among patients with Marfan syndrome or Loeys-Dietz syndrome were included in this analysis (Table 1). More patients who had a known diagnosis before delivery of either Marfan syndrome or Loeys-Dietz syndrome delivered at an academic hospital as opposed to a community hospital (78.6% vs 59.9%; P=.001). Patients with Marfan syndrome or Loeys-Dietz syndrome who delivered at academic centers were more likely to have an operative vaginal delivery than those who delivered at community centers (23.7% vs 8.6%; P=.002). When the indications for cesarean delivery were assessed, connective tissue disease was the primary indication for the mode of delivery at community centers when compared with academic centers (55.6% vs 43.5%; P=.02). There were higher rates of cesarean delivery for arrest of labor and/or malpresentation at community hospitals than at academic centers (23.6% vs 5.3%; P=.01). There were no differences between groups in terms of the method of anesthesia used for delivery. Among those with a known diagnosis of Marfan syndrome or Loeys-Dietz syndrome before delivery, there were increased operative vaginal delivery rates at academic hospitals than at community hospitals (27.2% vs 15.1%; P=.03) (Table 2). More patients with an aortic root measuring ≥4 cm before or after pregnancy delivered at academic centers as opposed to community centers (33.0% vs 10.2%; P=.01), but there were no significant differences in the median size of the aortic root during pregnancy or during the postpartum assessment between delivery locations. Cardiovascular complications were rare; 8 patients who delivered at academic centers and 7 patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (P=.79).

CONCLUSION

Patients with Marfan syndrome or Loeys-Dietz syndrome and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those who delivered at community hospitals had higher rates of cesarean delivery for the indication of Marfan syndrome or Loeys-Dietz syndrome. Optimal delivery management of these patients requires further prospective research.

Analysis of Cesarean Section Rates in a Public Tertiary Hospital During Teaching and Non-teaching Periods Using the Robson Ten Group Classification System

INTRODUCTION

The rising cesarean section (CS) rate is a global concern. One of the hospital characteristics that may explain the variation in CS among hospitals is hospital teaching status. This study aims to assess the rate of CS in a tertiary hospital during the teaching and non-teaching periods and to conduct an analysis using the Robson ten-group classification system.

METHODS

This study is a retrospective cohort that assessed pregnant mothers who gave birth at a tertiary hospital in Bandar Abbas. The study population was divided into two groups: those who gave birth during the hospital's teaching period (November 1st, 2019 to October 30th, 2020) and those who gave birth after that (November 1st, 2020 to October 30th, 2021). The primary outcome was the rate of CS according to Robson's classification system. The secondary outcome was the contributions of each group of Robson to the overall CS rate. Data were extracted by trained collectors from the "Iranian Maternal and Neonatal Network (IMaN Net)," a valid national system, using electronic patient records.

RESULTS

Of the total number of births (8382), 62.9 % occurred during the teaching period and 37.1 % during the non-teaching period. A 7% increase in CS was observed during the teaching period of the hospital compared to the non-teaching period (p<0.01). CS rate in Robson groups 1,2,4,7, and 10 differs significantly between teaching and non-teaching periods. According to the findings, Groups 5, 10, and 2 were the three most significant contributors to overall CS in our hospital during the study period.

CONCLUSION

The efforts to reduce the overall CS rate should be focused on groups 2,5, and 10 of Robson.

Office hours and caesarean section: systematic review and Meta-analysis

BACKGROUND

Unnecessary caesarean births may be affected by physician factors, such as preferences, incentives and convenience. Delivery during office hours can be a valuable proxy for measuring such effects.

OBJECTIVE

To determine the effect of office hours on the decision for caesarean delivery by assessing the odds of caesarean during office hours compared to out-of-office hours.

SEARCH STRATEGY

We searched CINAHL, ClinicalTrials.gov , The Cochrane Library, PubMed, Scopus and Web of Science from the beginning of records through August 2021.

DATA COLLECTION AND ANALYSIS

Search results were screened by three researchers. First, we selected studies that reported odds ratios of caesareans, or data allowing their calculation, for office and out-of-office hours. We extracted data on the study population, study design, data sources, setting, type of caesarean section, statistical analysis, and outcome measures. For groups reporting the same outcome, we performed a standard inverse-variance random-effects meta-analysis, which enabled us to calculate the overall odds ratios for each group. For groups reporting varying outcomes, we performed descriptive analysis.

MAIN RESULTS

Meta-analysis of weekday vs weekend for any caesarean section showed higher odds of caesarean during weekdays in adjusted analysis 1.40 (95%CI 1.13, 1.72 from 1,952,691 births). A similar effect was observed in the weekday vs Sunday comparison (1.39, 95%CI 1.10, 1.75, 150,932 births). A lower effect was observed for emergency CS, with a slight increase in adjusted analysis (1.06, 95%CI 0.90, 1.26, 2,622,772 births) and a slightly higher increase in unadjusted analysis (1.15, 95%CI 1.03, 1.29, 12,591,485 births). Similar trends were observed in subgroup analyses and descriptive synthesis of studies examining other office hours outcomes.

CONCLUSIONS

Delivery during office hours is associated with higher odds for overall caesarean sections and little to no effect for emergency caesarean. Non-clinical factors associated with office hours may influence the decision to deliver by caesarean section. Further detailed investigation of the "office hours effect" in delivery care is necessary and could lead to improvements in care systems.

FUNDING

The authors received no direct funding for this study.