Abstract
Objective
To establish the degree of variation across hospitals in the use of Caesarean delivery
for the indication of labour dystocia before and after accounting for maternal, fetal,
and hospital characteristics.
Methods
This study was a retrospective, population-based cohort study of nulliparous women
delivering term singletons in cephalic position following labour. Delivery visits
were extracted from three provincial perinatal registries in the Canadian provinces
of Ontario, Alberta, and British Columbia, from 2008-2012. Crude hospital-specific
rates of Caesarean delivery for labour dystocia were reported, and these rates were
then stabilized to account for hospitals with low delivery volumes. Rates were then
adjusted for maternal, fetal, and hospital characteristics using hierarchical logistic
regression.
Results
Among 403 205 women delivering at 170 hospitals, the overall Caesarean delivery rate
was 21.0%, and the rate of Caesarean delivery for labour dystocia was 12.7%, indicating
that 60% of all Caesarean deliveries were performed in part for this indication. The
middle 95% of hospitals had Caesarean delivery rates for labour dystocia ranging from
4.5% to 24.7%. Differences in maternal case mix and hospital characteristics explained
only a small proportion of this variation (95% central range 6.3%–21.7%).
Conclusion
Considerable inter-hospital variation in rates of Caesarean delivery for labour dystocia
remained after accounting for differences in maternal and hospital factors. Reporting
systems that monitor variation in inter-institutional rates should incorporate stabilization
and adjustment for case-mix differences and consider indication-specific rates of
Caesarean delivery to more fairly compare hospital performance and better target interventions
to reduce Caesarean delivery for specific indications.
Résumé
Objectif
Déterminer la variabilité dans le recours des différents hôpitaux à la césarienne
en cas de dystocie du travail, avec et sans prise en compte des caractéristiques du
fœtus, de la mère et de l'hôpital.
Méthodologie
Cette étude rétrospective d'une cohorte représentative de la population portait sur
des femmes primipares ayant accouché à terme d'un seul enfant en présentation céphalique
à la suite d'un travail. Les accouchements analysés ont eu lieu entre 2008 et 2012,
et les données ont été tirées des registres de données périnatales de trois provinces
canadiennes, soit l'Ontario, l'Alberta et la Colombie-Britannique. Le taux brut de
césarienne associée à une dystocie du travail a été établi pour chaque hôpital, puis
les différents taux ont été équilibrés pour tenir compte du faible volume d'accouchements
de certains établissements. Les taux ont ensuite été ajustés de nouveau, cette fois
pour tenir compte des caractéristiques du fœtus, de la mère et de l'hôpital, au moyen
d'une analyse de régression logistique hiérarchique.
Résultats
Pour les 403 205 accouchements analysés, survenus dans 170 hôpitaux, le taux de césarienne
global était de 21,0 %, alors que le taux de césarienne associée à une dystocie du
travail était de 12,7 %. Cette indication a donc été en cause dans 60 % des césariennes
pratiquées. Quatre-vingt-quinze pour cent des hôpitaux ont enregistré un taux de césarienne
associée à une dystocie du travail situé entre 4,5 % et 24,7 %. La variabilité des
caractéristiques de la mère et de l'hôpital n'expliquait qu'une petite partie de la
variation (intervalle couvrant 95 % des données, au centre de la distribution : 6,3
%–21,7 %).
Conclusion
La variabilité observée entre les différents hôpitaux pour ce qui est du taux de césarienne
associée à une dystocie du travail est demeurée importante une fois les caractéristiques
de la mère et de l'établissement prises en compte. Les systèmes mis en place pour
surveiller ce type de variabilité devraient équilibrer et corriger les données brutes
pour tenir compte de la variabilité des cas rencontrés et classer les taux de césarienne
par indications pour comparer plus équitablement les activités des hôpitaux et mieux
cibler les interventions nécessaires à la réduction du nombre d'accouchements par
césarienne associés à certaines indications.
Key Words
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Article info
Publication history
Published online: September 12, 2017
Accepted:
May 1,
2017
Received:
November 29,
2016
Footnotes
Competing interests: See Acknowledgements.
Identification
Copyright
© 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
