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Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk
Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model.Setting 146 English NHS trusts.Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008.Main outcome measure Rate of caesarean sections per 100 births (live or stillborn).Results Among 620604 singleton births, 147726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section.Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.Introduction Since the 1970s, many developed countries have experienced substantial growth in the rates of caesarean section.1 2 3 In England, for example, the rate of caesarean sections has increased from 9% in 1980 to 24.6% in 2008 9.4 5 6 Various reasons have been suggested for this increase, including rising maternal age at first pregnancy, technological advances that have improved the safety of the procedure, changes in women's preferences, and a growing proportion of women who have previously had a caesarean.7 8Nonetheless, there is concern about whether the current high rates of caesarean section are justified because the procedure is not without risk.9 Women may experience complications after caesarean section such as haemorrhage, infection, and thrombosis,10 and they have an increased risk of complications in subsequent pregnancies (such as uterine rupture and placenta praevia).11 12 13 Neonatal complications, although infrequent, include fetal respiratory distress syndrome, pulmonary hypertension, iatrogenic prematurity, and difficulty with bonding and breast feeding.8 9 14Adding to these concerns is evidence of considerable variation in rates of caesarean section within various countries,15 16 17 including the United Kingdom. In 2000, rates of caesarean section for singleton pregnancies in National Health Service (NHS) maternity units in England and Wales ranged from 10% to 43%.5 In April 2004, the National Institute for Health and Clinical Excellence (NICE) published guidance on caesarean section with the aim of ensuring consistency and quality of care.4 However, recent figures for births in England during 2008 9 show that rates of caesarean section still vary substantially among NHS trusts.6 These figures also appeared to show a north south divide, with higher rates in the south of England.The publication of the 2008 9 figures led to debate about potential causes of the variation in rates of caesarean section. These included differences in the clinical need of local populations, an increase in the number of women without risk factors requesting caesarean sections, a lack of midwives, and different attitudes and practices among professionals.18 19 How much these competing interpretations contributed to the variation is unclear. However, differences between local populations could have been discounted if the figures had been adjusted for maternal characteristics and clinical risk factors.We describe an analysis of NHS trust and regional rates of caesarean section for singleton pregnancies in England to examine whether the variation can be explained by maternal characteristics and clinical risk factors. We use funnel plots to illustrate whether the variation exceeds that expected from random fluctuations alone, and we extend previous work on rates of caesarean section in England5 by examining whether the variation is greater among women having an elective caesarean section or those having an emergency procedure.MethodsThe study used data from the hospital episode statistics database, which contains records of all patient admissions to NHS hospitals in England. Its core fields contain patient demographics and region of residence, and hospital administrative and clinical details. Diagnostic information is coded using the international classification of diseases, 10th revision (ICD 10), and operative procedures are described using the UK Office for Population Censuses and Surveys classification (OPCS), 4th revision. Hospital episode statistics also include additional fields (the "maternity tail") that capture information specific to deliveries, including onset of labour, parity, birth weight, and length of gestation. However, only around 75% of delivery records in the database have information in the maternity tail.DefinitionsWe extracted from the hospital episode statistics database records of women who delivered in English NHS acute trusts between 1 January and 31 December 2008. We restricted the sample to women aged between 15 and 44 years who had a singleton birth, and to NHS trusts whose obstetric units had more than 1000 deliveries in the 12 month period. Deliveries were included if the record contained information about mode of delivery in either the maternity tail or the procedure fields (OPCS codes: R17 to R25). The method of delivery was obtained primarily from the procedure fields. Where data had not been entered to these fields (0.6% of women), information was taken from the maternity tail. An elective caesarean section was defined by OPCS code R17, or by "mode of delivery" code 7 when data were obtained from the maternity tail. An emergency delivery was defined by codes R18 or 8, respectively.Data on maternal age at delivery, ethnicity, and the NHS trust and region of treatment were obtained from the core fields of the hospital episode statistics. Parity was obtained from the maternity tail. Where parity was not available, a woman was labelled as multiparous if she was found to have had a delivery episode in the previous 10 years of data (April 1997 to December 2007). Otherwise, she was assumed to be nulliparous (the median interval between first and second births is three years20). Among the 193637 women with parity data in the maternity tail, there was 84% agreement between the nulliparous and multiparous values derived from the maternity tail and those in imitation hermes belt sale historical data (kappa=0.69). The majority (92%) of disagreements were because a previous pregnancy could not be identified in the historical data.Risk factors for caesarean section were identified using all ICD 10 diagnosis fields (see web appendix for exact definitions), which had been adapted from a previously published classification system.21 A previous caesarean section was defined if any diagnosis code indicated a "uterine scar from previous surgery" (ICD 10: O34.2) among multiparous women or if a woman had delivered by caesarean according to the previous 10 years of hospital episode statistics. Among the 312407 multiparous classifications, there was 91% agreement between the coding of a "uterine scar" and a previous caesarean section in the historical data (kappa=0.66). Most (90%) disagreements arose because a previous caesarean section was found in the historical data for a woman without the coding for a scar.Finally, socioeconomic deprivation was defined using a five category indicator that was derived from the English Indices of Deprivation 2004 ranking of the English super output areas.22 The categories were defined by partitioning the ranks of the 32480 areas into quintiles (for example, 0 20th percentiles, 20 40th percentiles) and were labelled 1 (least deprived) to 5 (most deprived). Women were allocated a category on the basis of their region of residence. Where this was missing (1.1% of women), a woman was allocated to the deprivation category that was most common among the women delivering at their NHS trust.Statistical analysisThe unadjusted rate of caesarean sections for each NHS trust was expressed as a percentage of all live or stillborn births.Multiple logistic regression was used to estimate the probability of a woman having had a caesarean section on the basis of her age, ethnicity, level of socioeconomic deprivation, and clinical risk factors for caesarean section. Interactions between maternal age and the clinical risk factors were examined but were not included in the final model because they did not significantly improve the model's fit (likelihood ratio test, P value>0.3). The ability of the logistic model to discriminate between women who had a vaginal delivery and those who had a caesarean section was summarised using the C statistic. A C statistic of 0.5 indicates that the model discriminates no better than chance alone, whereas a value of 1.0 indicates perfect discrimination.23 Hermes belt replica The probabilities of caesarean section for women who delivered at the same NHS trust were summed to give the trust's predicted rate of caesarean section. Risk adjusted rates of caesarean section for each NHS trust were produced by dividing the trust's unadjusted caesarean section rate by its predicted rate, and multiplying this ratio by the national caesarean section rate. An equivalent process was used to produce adjusted rates for rates of emergency and elective caesarean section. However, because there were now three outcomes (vaginal delivery, elective caesarean section, and emergency caesarean section), we used multinomial logistic regression to estimate the probability of each mode of delivery.Funnel plots were used to examine the variation among NHS trusts in both crude and risk adjusted rates of caesarean section.24 These plots "test" whether the rate of caesarean sections of a NHS trust differs significantly from the national rate for England, assuming the trust's rate is only influenced by sampling variation (that is, random errors). The plot contains two funnel limits. Assuming differences arise from random errors alone, the chance of the trust being within the limits is 95% for the inside funnel and 99.8% for the outer funnel. We measured the amount of variation between NHS trusts above that expected from sampling variation by using a random effects approach.24 This estimates an "overdispersion" term that, when added to the sampling variance of each NHS trust, would inflate the funnel limits to fit the observed distribution of caesarean section rates.Differences between groups were tested using the 2 test. All P values were two sided, and those lower than 0.05 hermes men belt replica were judged to be statistically significant. To account for a lack of independence in the data of women treated in the same trust, the standard errors of the regression model coefficients were calculated using a clustered sandwich estimator. STATA (version 10) was used for all statistical calculations.ResultsBetween 1 January and 31 December 2008, 620604 singleton births took place at 146 NHS trusts among women resident in England. Of these, 397573 (64.1%) were normal vaginal deliveries and 75305 (12.1%) were vaginal deliveries in which medical instruments were used. The average age of these women was 28.9 years (SD 6.0 years) and, among the 552290 women with known ethnicity, 124004 (22.5%) were not white.There were 147726 caesarean sections during this period, giving an overall national caesarean section rate of 23.8% for women in England with singleton births. These 147726 caesarean sections consisted of 57892 (9.3%) elective and 89834 (14.5%) emergency procedures.Association Hermes belts replica paris between caesarean section and patient factorsThe proportion of women who had a caesarean section differed according to maternal characteristics and clinical risk factors (table 1). A quarter (25%) of nulliparous women had a caesarean section, whereas only 9% of multiparous women underwent a caesarean section if they had no history of caesarean delivery. Women were more likely to have had a caesarean section if they had previously had a caesarean (71%), their baby had a breech presentation (90%), or they had placenta praevia or placental abruption (85%). Among the 46748 women with a previous caesarean section and who delivered by caesarean, 32493 (70%) had an elective procedure. Similarly, 11151 (57%) of the 19656 women who delivered a breech baby by caesarean had an elective procedure. Overall, 72% of elective caesarean sections (41709/57892) were performed for breech presentation or because of a previous caesarean section.Table 1 Unadjusted rates of caesarean section according to maternal characteristics and clinical risk factorsView this table:View popupView inlineA total of 313987 women, 51% of the overall sample, had none of the specified clinical risk factors for a caesarean section. Just 15431 (4.9%) of these women had a caesarean delivery. These caesarean sections consisted of 4499 (29%) emergency deliveries and 10932 (71%) elective procedures. The proportion of women with no clinical risk factors who had a caesarean section increased with maternal age, ranging from 1.7% (387/22812) for women aged under 20 years to 9.2% (5021/54288) for women aged 35 years or over.Table 2 summarises the risk of a caesarean section associated with the maternal characteristics and clinical risk factors studied. The likelihood of a caesarean section was higher in older women, independent of other risks, and in Afro Caribbean women. The odds ratios of caesarean section were greatest for women who had placenta praevia or placental abruption, previously had caesarean section, or had breech presentation. The influences of other obstetrical complications such as dystocia and fetal distress were significant but less marked. Overall, the regression model discriminated well between women who did and those who did not deliver by caesarean (C statistic=0.86).
Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model.Setting 146 English NHS trusts.Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008.Main outcome measure Rate of caesarean sections per 100 births (live or stillborn).Results Among 620604 singleton births, 147726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section.Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.Introduction Since the 1970s, many developed countries have experienced substantial growth in the rates of caesarean section.1 2 3 In England, for example, the rate of caesarean sections has increased from 9% in 1980 to 24.6% in 2008 9.4 5 6 Various reasons have been suggested for this increase, including rising maternal age at first pregnancy, technological advances that have improved the safety of the procedure, changes in women's preferences, and a growing proportion of women who have previously had a caesarean.7 8Nonetheless, there is concern about whether the current high rates of caesarean section are justified because the procedure is not without risk.9 Women may experience complications after caesarean section such as haemorrhage, infection, and thrombosis,10 and they have an increased risk of complications in subsequent pregnancies (such as uterine rupture and placenta praevia).11 12 13 Neonatal complications, although infrequent, include fetal respiratory distress syndrome, pulmonary hypertension, iatrogenic prematurity, and difficulty with bonding and breast feeding.8 9 14Adding to these concerns is evidence of considerable variation in rates of caesarean section within various countries,15 16 17 including the United Kingdom. In 2000, rates of caesarean section for singleton pregnancies in National Health Service (NHS) maternity units in England and Wales ranged from 10% to 43%.5 In April 2004, the National Institute for Health and Clinical Excellence (NICE) published guidance on caesarean section with the aim of ensuring consistency and quality of care.4 However, recent figures for births in England during 2008 9 show that rates of caesarean section still vary substantially among NHS trusts.6 These figures also appeared to show a north south divide, with higher rates in the south of England.The publication of the 2008 9 figures led to debate about potential causes of the variation in rates of caesarean section. These included differences in the clinical need of local populations, an increase in the number of women without risk factors requesting caesarean sections, a lack of midwives, and different attitudes and practices among professionals.18 19 How much these competing interpretations contributed to the variation is unclear. However, differences between local populations could have been discounted if the figures had been adjusted for maternal characteristics and clinical risk factors.We describe an analysis of NHS trust and regional rates of caesarean section for singleton pregnancies in England to examine whether the variation can be explained by maternal characteristics and clinical risk factors. We use funnel plots to illustrate whether the variation exceeds that expected from random fluctuations alone, and we extend previous work on rates of caesarean section in England5 by examining whether the variation is greater among women having an elective caesarean section or those having an emergency procedure.MethodsThe study used data from the hospital episode statistics database, which contains records of all patient admissions to NHS hospitals in England. Its core fields contain patient demographics and region of residence, and hospital administrative and clinical details. Diagnostic information is coded using the international classification of diseases, 10th revision (ICD 10), and operative procedures are described using the UK Office for Population Censuses and Surveys classification (OPCS), 4th revision. Hospital episode statistics also include additional fields (the "maternity tail") that capture information specific to deliveries, including onset of labour, parity, birth weight, and length of gestation. However, only around 75% of delivery records in the database have information in the maternity tail.DefinitionsWe extracted from the hospital episode statistics database records of women who delivered in English NHS acute trusts between 1 January and 31 December 2008. We restricted the sample to women aged between 15 and 44 years who had a singleton birth, and to NHS trusts whose obstetric units had more than 1000 deliveries in the 12 month period. Deliveries were included if the record contained information about mode of delivery in either the maternity tail or the procedure fields (OPCS codes: R17 to R25). The method of delivery was obtained primarily from the procedure fields. Where data had not been entered to these fields (0.6% of women), information was taken from the maternity tail. An elective caesarean section was defined by OPCS code R17, or by "mode of delivery" code 7 when data were obtained from the maternity tail. An emergency delivery was defined by codes R18 or 8, respectively.Data on maternal age at delivery, ethnicity, and the NHS trust and region of treatment were obtained from the core fields of the hospital episode statistics. Parity was obtained from the maternity tail. Where parity was not available, a woman was labelled as multiparous if she was found to have had a delivery episode in the previous 10 years of data (April 1997 to December 2007). Otherwise, she was assumed to be nulliparous (the median interval between first and second births is three years20). Among the 193637 women with parity data in the maternity tail, there was 84% agreement between the nulliparous and multiparous values derived from the maternity tail and those in imitation hermes belt sale historical data (kappa=0.69). The majority (92%) of disagreements were because a previous pregnancy could not be identified in the historical data.Risk factors for caesarean section were identified using all ICD 10 diagnosis fields (see web appendix for exact definitions), which had been adapted from a previously published classification system.21 A previous caesarean section was defined if any diagnosis code indicated a "uterine scar from previous surgery" (ICD 10: O34.2) among multiparous women or if a woman had delivered by caesarean according to the previous 10 years of hospital episode statistics. Among the 312407 multiparous classifications, there was 91% agreement between the coding of a "uterine scar" and a previous caesarean section in the historical data (kappa=0.66). Most (90%) disagreements arose because a previous caesarean section was found in the historical data for a woman without the coding for a scar.Finally, socioeconomic deprivation was defined using a five category indicator that was derived from the English Indices of Deprivation 2004 ranking of the English super output areas.22 The categories were defined by partitioning the ranks of the 32480 areas into quintiles (for example, 0 20th percentiles, 20 40th percentiles) and were labelled 1 (least deprived) to 5 (most deprived). Women were allocated a category on the basis of their region of residence. Where this was missing (1.1% of women), a woman was allocated to the deprivation category that was most common among the women delivering at their NHS trust.Statistical analysisThe unadjusted rate of caesarean sections for each NHS trust was expressed as a percentage of all live or stillborn births.Multiple logistic regression was used to estimate the probability of a woman having had a caesarean section on the basis of her age, ethnicity, level of socioeconomic deprivation, and clinical risk factors for caesarean section. Interactions between maternal age and the clinical risk factors were examined but were not included in the final model because they did not significantly improve the model's fit (likelihood ratio test, P value>0.3). The ability of the logistic model to discriminate between women who had a vaginal delivery and those who had a caesarean section was summarised using the C statistic. A C statistic of 0.5 indicates that the model discriminates no better than chance alone, whereas a value of 1.0 indicates perfect discrimination.23 Hermes belt replica The probabilities of caesarean section for women who delivered at the same NHS trust were summed to give the trust's predicted rate of caesarean section. Risk adjusted rates of caesarean section for each NHS trust were produced by dividing the trust's unadjusted caesarean section rate by its predicted rate, and multiplying this ratio by the national caesarean section rate. An equivalent process was used to produce adjusted rates for rates of emergency and elective caesarean section. However, because there were now three outcomes (vaginal delivery, elective caesarean section, and emergency caesarean section), we used multinomial logistic regression to estimate the probability of each mode of delivery.Funnel plots were used to examine the variation among NHS trusts in both crude and risk adjusted rates of caesarean section.24 These plots "test" whether the rate of caesarean sections of a NHS trust differs significantly from the national rate for England, assuming the trust's rate is only influenced by sampling variation (that is, random errors). The plot contains two funnel limits. Assuming differences arise from random errors alone, the chance of the trust being within the limits is 95% for the inside funnel and 99.8% for the outer funnel. We measured the amount of variation between NHS trusts above that expected from sampling variation by using a random effects approach.24 This estimates an "overdispersion" term that, when added to the sampling variance of each NHS trust, would inflate the funnel limits to fit the observed distribution of caesarean section rates.Differences between groups were tested using the 2 test. All P values were two sided, and those lower than 0.05 hermes men belt replica were judged to be statistically significant. To account for a lack of independence in the data of women treated in the same trust, the standard errors of the regression model coefficients were calculated using a clustered sandwich estimator. STATA (version 10) was used for all statistical calculations.ResultsBetween 1 January and 31 December 2008, 620604 singleton births took place at 146 NHS trusts among women resident in England. Of these, 397573 (64.1%) were normal vaginal deliveries and 75305 (12.1%) were vaginal deliveries in which medical instruments were used. The average age of these women was 28.9 years (SD 6.0 years) and, among the 552290 women with known ethnicity, 124004 (22.5%) were not white.There were 147726 caesarean sections during this period, giving an overall national caesarean section rate of 23.8% for women in England with singleton births. These 147726 caesarean sections consisted of 57892 (9.3%) elective and 89834 (14.5%) emergency procedures.Association Hermes belts replica paris between caesarean section and patient factorsThe proportion of women who had a caesarean section differed according to maternal characteristics and clinical risk factors (table 1). A quarter (25%) of nulliparous women had a caesarean section, whereas only 9% of multiparous women underwent a caesarean section if they had no history of caesarean delivery. Women were more likely to have had a caesarean section if they had previously had a caesarean (71%), their baby had a breech presentation (90%), or they had placenta praevia or placental abruption (85%). Among the 46748 women with a previous caesarean section and who delivered by caesarean, 32493 (70%) had an elective procedure. Similarly, 11151 (57%) of the 19656 women who delivered a breech baby by caesarean had an elective procedure. Overall, 72% of elective caesarean sections (41709/57892) were performed for breech presentation or because of a previous caesarean section.Table 1 Unadjusted rates of caesarean section according to maternal characteristics and clinical risk factorsView this table:View popupView inlineA total of 313987 women, 51% of the overall sample, had none of the specified clinical risk factors for a caesarean section. Just 15431 (4.9%) of these women had a caesarean delivery. These caesarean sections consisted of 4499 (29%) emergency deliveries and 10932 (71%) elective procedures. The proportion of women with no clinical risk factors who had a caesarean section increased with maternal age, ranging from 1.7% (387/22812) for women aged under 20 years to 9.2% (5021/54288) for women aged 35 years or over.Table 2 summarises the risk of a caesarean section associated with the maternal characteristics and clinical risk factors studied. The likelihood of a caesarean section was higher in older women, independent of other risks, and in Afro Caribbean women. The odds ratios of caesarean section were greatest for women who had placenta praevia or placental abruption, previously had caesarean section, or had breech presentation. The influences of other obstetrical complications such as dystocia and fetal distress were significant but less marked. Overall, the regression model discriminated well between women who did and those who did not deliver by caesarean (C statistic=0.86).
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