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Inter-institutional Variation in Use of Caesarean Delivery for Labour Dystocia

Published:September 12, 2017DOI:https://doi.org/10.1016/j.jogc.2017.05.003

      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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