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Istituto Superiore di Sanità
EpiCentro - L'epidemiologia per la sanità pubblica
Istituto Superiore di Sanità - EpiCentro


Prevalence of Cesarean Section and its Relation to Type of Delivery Facility, Campania

Roberta Arsieri (1), Vincenzo Formisano (1), Aniello Pugliese (2), Maurizio Saporito (2), and Maria Triassi (1)

(1)  Department of Medical and Preventive Sciences, Section of Hygiene and Preventive Medicine, University Federico II, Naples
(2)  A. Cardarelli Hospital Agency, Naples

 

In the last 10 years, the frequency of Cesarean sections (C-sections) in Italy has increased substantially. The increase has been particularly marked in the Campania region of Southern Italy, which, since 1996, has been the region with the highest rate of cesarean deliveries. The percent of deliveries via C-section has risen from 36.3% in 1996 to 51.4% in 200 (1). Between 1996 and 1999, the rate of increase was similar in both public and private structures working under contract with the government, although C-section rate in the private structures is consistently 1.3 times higher than in public facilities (2). During the same period, little change has occurred in the characteristics of the maternal and neonatal populations, and perinatal outcomes have remained essentially unchanged.

 

The present article attempts to evaluate whether facility-specific rates of C-section differ among primary and referral facilities and are related to the risk characteristics of the births occurring in these facilities. The study presented here was conducted as part of routine surveillance of natality in Campania that uses the certificates that are routinely completed on the characteristics of deliveries (CedAP; Certificati di Assistenza al Parto). Data were examined from the 27 delivery sites that submitted a CedAP form for at least 65% of the deliveries conducted in their facilities. These structures provided data on 17,799 births for 2000, while data were unavailable for 7,236 (29%) of the total births in these same facilities. Comparisons with birth records obtained from the National Institute of Statistics (ISTAT) for Campania for 1997 (3) do not show any major differences in the characteristics of the infants for whom information was and was not available with respect to sex, vital status, weight, gestational age, and parity, suggesting no systematic bias in the availability of certificates.

 

The types of facilities were subdivided into two groups based on the availability of neonatal intensive care beds. This criterion, in the absence of accreditation criteria established by the regional health authorities, allowed us to distinguish level 3 facilities from those of level 1 and 2.

 

The table provides data for the four level 3 facilities and the 23 level 1 and 2 facilities, including 6 hospitals with more than 1000 deliveries per year, 6 with 500-999 deliveries/year, 3 with less than 500 per year, and 12 private clinics working under contract (2 with more than 1000 births per year, 8 with 500-99/year, and 2 with less than 500/year). The level 3 facilities consisted on 1 private clinic and 3 hospitals, all of which had more than 1000 births/year.

C-sections accounted for 50% of the births, with higher rates seen in the level 1 and level 2 facilities (52%) compared with the level 3 facilities (41%). Low birth weight infants and twins, as expected, accounted for a higher percentage of the deliveries performed in the Level 3 facilities, while non-cephalic presentations accounted for a lower proportion than in the level 1 and 2 facilities. The frequency of C-sections for each of these three categories of neonates was higher in the Level 1 and 2 facilities than in the Level 3 facilities except for preterm infants, although the difference was statistically significant only for the neonates with non-cephalic presentations.

In the Level 3 structures, the percentage of mothers over 34 years of age was higher than in Level 1 and 2 structures, while the distribution of nulliparous women was the same. Among nulliparous women, the C-section rate was significantly higher in the Level 1 and 2 facilities.

 

In conclusion, the frequency of C-sections between structures of different levels showed a distribution contrary to that which would have been expected based on the characteristics of the mothers and their infants. The fact that equal percentages of the populations delivering in both types of facilities were nulliparous and that the C-section rate was higher among nulliparous women in the Level 1 and 2 facilities suggests that the difference between the two types of facilities cannot be attributed only to differences in repeat C-section rates.  Furthermore, the greater concentration of infants with non-cephalic presentations explains relatively little of the difference in C-section rates between the two types of facilities because these conditions account for only a small percentage of total deliveries. Although the Level 3 facilities might be expected to have a higher rate of C-sections among premature infants because of concomitant pathologies in this group, this was not the case; indeed the frequency was actually higher for premature infants in the Level 1 and 2 facilities. The statistically significantly higher rates among older and nulliparous women in the Level 1 and 2 facilities suggests other factors than medical emergencies may be operative. C-sections can be scheduled on an elective basis, which presents a clear advantage to the physician; indeed this is confirmed by the finding that most C-sections are performed on weekday mornings (1).

 

In non-emergency situations, C-sections carry a higher risk of morbidity and mortality for the mother compared with vaginal deliveries (4). This study demonstrates the need to further evaluate the non-medical factors contributed to the elevated frequency of C-sections in facilities providing care to pregnant women at low risk of adverse pregnancy outcomes.

 

Comment

Gianfranco Gori

Unita’ Operativa Ostetrica Ginecologica

Local Health Agency, Forlì, Emilia-Romagna Region

 

Until the end of the 1960s, the C-section rate in Italy was approximately 5%; starting in the 1970s, it began to increase rapidly, tripling by the end of the 1970s and increasing 5-fold by the end of the 1980s. This increase has been accompanied by substantial human and medical costs. The risk of maternal deaths is in fact 4-8 times higher than with vaginal deliveries and morbidity is 10-15 times higher. The higher maternal risks are not, however, counterbalanced by an improvement in perinatal outcomes.

 

The data presented by Arsieri adds an important element to the analysis of the worrisome trend through its examination of the types of facilities in which C-sections are being performed. Indeed, those structures that are meant to provide care for low-risk pregnancies have C-section rates higher than those that are meant to provide care for more complicated pregnancies. Although caution is needed in the interpretation of data from the CEDAP system, the results raise interesting questions about the reasons behind this phenomenon.

 

With respect to clinical and organizational factors, a contributor to the increase in C-section rates may be the result of a progressive loss of clinical competence caused by deficits in the training of specialists, of poor knowledge of the physiology of pregnancy and delivery, and of the large number of facilities providing such deliveries such that many perform few deliveries annually. The low number of deliveries creates conditions which favor “preventive” C-sections in an attempt to avoid real obstetrical emergencies to which it would not be possible to respond either because of lack of personnel or clinical competence.

 

One solution that could resolve some of the clinical and organizational problems would be the creation/implementation of networks in which the places where deliveries are conducted would be organized in networks according to a hub-and-spoke model (central and peripheral structures) in which explicit criteria would be used to determine the most appropriate delivery point for each woman based on her risk status and in which the center would assist in the diffusion of clinical competence towards the periphery of the network.

 

A factor that is not clinical or organizational that nonetheless contributes to the elevated rates of C-section is that C-section is increasingly considered by women and their doctors as simply an equal alternative to vaginal delivery and thus the choice of C-section is conditioned by the requests, judgment, prejudices, and values associated with reproduction (5). To combat this situation, experiences reported in the literature (6, 7) suggest that implementation of procedures based on evidence, working groups, and changing beliefs about the delivery process are necessary (7).

 

BIBLIOGRAPHY

1. Arsieri R, Pugliese A, Saporito M, et al. Rapporto sulla natalità in Campania - 2000. Napoli. 2001.

2. Pizzuti R, de Campora E, Lodato S. Not Ist Super Sanità 2001; 14(5) - Inserto BEN: i-iii.

3. ISTAT. Sistema sanitario e salute della popolazione indicatori regionali (Informazioni n. 16). 2000.

4. Hall MH, Bewley S. Lancet 1999; 354: 776.

5. www.saperidoc.it/ques_240.html

6. Basevi V, Cerrone L, Gori G. Epid Prev 1994; 18: 194-9.

7. Johanson R, Newburn M. BMJ 2002; 324: 892-5.