Urbanization and the likelihood of a cesarean section

Variations in the prevalence of caesarean section deliveries in India between 2016 and 2021 - an analysis of Tamil Nadu and Chhattisgarh

BACKGROUND

The prevalence of C-sections in India increased from 17.2% to 2006 to 21.5% in 2021. This study examines the variations in C-section prevalence and the factors correlating to these variations in Tamil Nadu (TN) and Chhattisgarh (CG).

METHODS

Delivery by C-section as the outcome variable and several demographic, socio-economic, and clinical variables were considered as explanatory variables to draw inferences from unit-level data from the National Family Health Survey (NFHS-4; 2015-16 and NFHS-5; 2019-21). Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed. The Slope Index of Inequality (SII) and the Concentration Index (CIX) were used to analyse absolute and relative inequality in C-section rates across wealth quintiles in public- and private-sector institutions.

RESULTS

The prevalence of C-sections increased across India, TN and CG despite a decrease in pregnancy complications among the study participants. The odds of caesarean deliveries among overweight women were twice (OR = 2.11; 95% CI 1.95-2.29; NFHS-5) those for underweight women. Women aged 35-49 were also twice (OR = 2.10; 95% CI 1.92-2.29; NFHS-5) as likely as those aged 15-24 to have C-sections. In India, women delivering in private health facilities had nearly four times higher odds (OR = 3.90; 95% CI 3.74-4.06; NFHS-5) of having a C-section; in CG, the odds were nearly ten-fold (OR = 9.57; 95% CI:7.51,12.20; NFHS-5); and in TN, nearly three-fold (OR = 2.65; 95% CI-2.27-3.10; NFHS-5) compared to those delivering in public facilities. In public facilities, absolute inequality by wealth quintile in C-section prevalence across India and in CG increased in the five years until 2021, indicating that the rich increasingly delivered via C-sections. In private facilities, the gap in C-section prevalence between the poor (the bottom two quintiles) and the non-poor narrowed across India. In TN, the pattern was inverted in 2021, with an alarming 73% of the poor delivering via C-sections compared to 64% of those classified as non-poor.

CONCLUSION

The type of health facility (public or private) had the most impact on whether delivery was by C-section. In India and CG, the rich are more likely to have C-sections, both in the private and in the public sector. In TN, a state with good health indicators overall, the poor are surprisingly more likely to have C-sections in the private sector. While the reasons for this inversion are not immediately evident, the implications are worrisome and pose public health policy challenges.

Cesarean Delivery and Gender of Delivering Physicians: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the association of the gender of the delivering physician and the odds of performing cesarean delivery.

DATA SOURCES

CINAHL, ClinicalTrials.gov, Cochrane Library, PubMed, Scopus and Web of Science from the first year of records through May 2020.

METHODS OF STUDY SELECTION

We included studies that reported odds ratios (OR), or data allowing the calculation of ORs, for cesarean delivery performed by female and male delivering physicians. We also included studies that reported the preference of physicians for performing cesarean deliveries.

TABULATION, INTEGRATION, AND RESULTS

Independent data extraction was carried out by at least two researchers. Standard inverse-variance random effects meta-analysis was used to generate overall ORs. Finally, in two separate meta-analyses, we analyzed 15 studies containing clinical data for 1,269,625 births, and 11 studies containing data for the preference for delivery mode of 4,911 obstetricians. Both the crude and adjusted odds of a cesarean delivery were lower for those performed by female physicians (crude OR 0.75, 95% CI 0.68-0.84, τ=0.029, adjusted OR 0.74, 95% CI 0.65-0.85, τ=0.031). We also found that female physicians had a lower preference for cesarean delivery in both crude and adjusted analysis (crude OR 0.59, 95% CI 0.36-0.96, I=77%, adjusted OR 0.58, 95% CI 0.40-0.84, I=67%).

CONCLUSION

Female physicians are less likely to perform cesarean delivery and less likely to prefer it. This was observed across different health systems and populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020158442.

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

OBJECTIVE

The aim of this study is to determine the odds of caesarean section in all births in teaching hospitals as compared with non-teaching hospitals.

SETTING

Over 3600 teaching and non-teaching hospitals in 22 countries. We searched CINAHL, The Cochrane Library, PubMed, sciELO, Scopus and Web of Science from the beginning of records until May 2020.

PARTICIPANTS

Women at birth. Over 18.5 million births.

INTERVENTION

Caesarean section.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures are the adjusted OR of caesarean section in a variety of teaching hospital comparisons. The secondary outcome is the crude OR of caesarean section in a variety of teaching hospital comparisons.

RESULTS

In adjusted analyses, we found that university hospitals have lower odds than non-teaching hospitals (OR=0.66, 95% CI 0.56 to 0.78) and other teaching hospitals (OR=0.46, 95% CI 0.24 to 0.89), and no significant difference with unspecified teaching status hospitals (OR=0.92, 95% CI 0.80 to 1.05, τ2=0.009). Other teaching hospitals had higher odds than non-teaching hospitals (OR=1.23, 95% CI 1.12 to 1.35). Comparison between unspecified teaching hospitals and non-teaching hospitals (OR=0.91, 95% CI 0.50 to 1.65, τ2=1.007) and unspecified hospitals (OR=0.95, 95% CI 0.76 to 1.20), τ2<0.001) showed no significant difference. While the main analysis in larger sized groups of analysed studies reveals no effect between hospitals, subgroup analyses show that teaching hospitals carry out fewer caesarean sections in several countries, for several study populations and population characteristics.

CONCLUSIONS

With smaller sample of participants and studies, in clearly defined hospitals categories under comparison, we see that university hospitals have lower odds for caesarean. With larger sample size and number of studies, as well as less clearly defined categories of hospitals, we see no significant difference in the likelihood of caesarean sections between teaching and non-teaching hospitals. Nevertheless, even in groups with no significant effect, teaching hospitals have a lower or higher likelihood of caesarean sections in several analysed subgroups. Therefore, we recommend a more precise examination of forces sustaining these trends.

PROSPERO REGISTRATION NUMBER

CRD42020158437.

Magnitude and correlates of caesarean section in urban and rural areas: A multivariate study in Vietnam

Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs.

First Fall-Related Injuries Requiring Hospitalization Increase the Risk of Recurrent Injurious Falls: A Nationwide Cohort Study in Taiwan

Objectives

Recurrent falls not only have risk factors different from those of single falls but also have less favorable outcomes. The aim of our study was to determine the association between the injury characteristics of a first fall and the likelihood of recurrent injurious falls in a cohort of hospitalized patients.

Methods

We designed a nationwide retrospective cohort study and selected hospitalized patients who had injurious falls between 2001 and 2010. Cox proportional hazards models were used to estimate the hazard ratios (HRs) of recurrent injurious falls requiring hospitalization in the following year on the basis of the patients’ demographic characteristics, comorbidities, and the characteristics of injuries from the first injurious fall requiring hospitalization.

Results

Among the 504 512 patients hospitalized for injurious falls, 19 442 experienced recurrent injurious falls requiring hospitalization. The 1-year incidence of recurrent injurious falls requiring hospitalization was 3.85%. The incidence density was the highest within the 3-month period after the first injurious fall. The risk of recurrent injurious falls among patients aged 40 to 64, 65 to 74, and ≥ 75 years increased progressively (HR: 2.11, 95% confidence interval [CI]: 1.90–2.34; HR: 2.80, 95% CI: 2.51–3.11; and HR: 3.80, 95% CI: 3.42–4.23, respectively). The length of hospitalization (LOH) ≥ 15 or ≥ 31 days (HR: 1.39, 95% CI: 1.30–1.48; and HR: 1.59, 95% CI: 1.43–1.77, respectively) and injury to the head (HR: 1.59, 95% CI: 1.53–1.65) or spine (HR: 1.66, 95% CI: 1.59–1.74) were also found to be major risk factors.

Conclusions

Our findings show that the LOH and head and spine injuries are associated with an increased risk of recurrent injurious falls leading to hospitalization. The risk of recurrent injurious falls requiring hospitalization increased significantly among adults older than 40 years. We suggest further research on the effects of injury characteristics associated with the first injurious fall requiring hospitalization and resultant anatomical damages on the risk of recurrent injurious falls requiring hospitalization. High-risk patients should receive tailored rehabilitation addressing their respective injuries within 3 months after hospital discharge.

Risk of Diabetes Mellitus after First-Attack Acute Pancreatitis: A National Population-Based Study

OBJECTIVES

Population-based data on the risk of diabetes mellitus onset after acute pancreatitis (AP) are lacking. We assessed the incidence of diabetes in AP survivors compared with matched controls.

METHODS

The study cohort, drawn from Taiwan National Health Insurance claims data, included 2,966 first-attack AP patients and 11,864 non-AP general controls individually matched on age and sex, with an AP/non-AP ratio of 1:4. Incidence rate was estimated under Poisson assumption. Relative risks of diabetes were indicated by hazard ratios (HRs) estimated from Cox proportional hazard regression models with a partitioning of time at 3 months to account for proportionality.

RESULTS

In the first partition of time (<3 months), the incidences of diabetes were 60.8 and 8.0 per 1,000 person-years in AP and control groups, respectively; representing a covariate-adjusted HR of 5.90 (95% confidence interval (CI) 3.37-10.34). In the second partition (≥3 months), the incidences of diabetes were 22.5 and 6.7 per 1,000 person-years in AP and control groups, respectively (adjusted HR 2.54, 95% CI 2.13-3.04). In the second partition, the risk of diabetes was greater in men than in women (HR 3.21 vs. 1.58, P=0.0004). When the analyses were stratified by severity of AP, the results for mild AP were similar to those for all AP.

CONCLUSIONS

The risk of diabetes increases by twofold after AP; therefore, a long-term screening is necessary to evaluate diabetes after an attack regardless of severity. Further research should be conducted to develop cost-effective follow-up strategies, and to elucidate the underlying mechanisms of the relationship between diabetes and AP.

Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey

Background

Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.

Methods

We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007–10/01/2008). Data were collected regarding women’s characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.

Results

Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).

Conclusions

We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Factors on the Gap between Predicted Cesarean Section Rate and Real Cesarean Section Rate in Tertiary Hospitals

PURPOSE

This study was aimed to examine the gap between predicted cesarean section rate and real cesarean section rate and it's determining factors of 44 tertiary hospitals.

METHOD

This study is a cross-sectional analysis using the data of 25,623 deliveries in 2009 drawn from homepage of Health Insurance Review and Assessment Service. Data were analyzed with t-test, F-test, Scheffe? test, and logistic regression.

RESULT

There were statistically significant differences in the gap of cesarean section rate (more gap indicates higher quality of delivery) by grade of nurse staffing and delivery cases. Hospitals with nurse staffing grade 1 to 2 had more possibility to be classified into higher grade in quality of delivery (OR 5.67, 95% CI 1.07~30.08). Also hospitals with over 500 delivery cases had more possibility be classified into higher grade in quality of delivery (OR 4.92, 95% CI 1.14~21.23, respectively).

CONCLUSION

The finding suggests that grade of nurse staffing may influence the real cesarean section rate because nurses do a vital role to prevent unnecessary cesarean section. Further study is required to provide evidence that nurse staffing influence on patient outcome and cost-effectiveness in order to obtain adequate number of nursing staffs.

Population-based estimates of medical comorbidities in erectile dysfunction in a Taiwanese population

INTRODUCTION

Erectile dysfunction (ED) is usually associated with systemic disorders. This population-based study supports and expands on previous research. It also presents data in a Taiwanese male population where existing data on this topic remain sparse.

AIM

The aim of this study is to analyze the prevalence and risk of 36 medical comorbidities in patients with ED compared with the general population.

METHODS

A total of 2,213 patients with ED and 11,065 matching controls were selected from the Taiwan National Health Insurance Research Dataset. We chose 22 comorbidities from the Elixhauser comorbidity index, 10 highly prevalent medical conditions in an Asian population, and four male gender-specific comorbidities for analysis.

MAIN OUTCOME MEASUREMENT

Conditional logistic regression analyses conditioned on age group and monthly income were performed to investigate the risk of various comorbidities for patients with and without ED, after adjusting for the geographic region and level of urbanization of the patient's community.

RESULTS

Patients with ED were at an increased risk for multiple systemic comorbidities. Conditional regression analyses showed that patients with ED were at a higher risk for hypertrophy of the prostate (odds ratio [OR] = 12.87), chronic prostatitis (OR = 9.36), alcohol abuse (OR = 3.60), drug abuse (OR = 2.62), urinary incontinence (OR = 2.58), ankylosing spondylitis (OR = 2.19), peripheral vascular disorder (OR = 1.98), ischemic heart disease (OR = 1.94), psychoses (OR = 1.97), depression (OR = 1.88), uncomplicated diabetes (OR = 1.91), complicated diabetes (OR = 1.84), hepatitis B or C (OR = 1.71), hyperlipidemia (OR = 1.69), and chronic pulmonary disease (OR = 1.55) than patients without ED.

CONCLUSION

The results show that patients with ED have a higher prevalence of multiple noncardiovascular comorbidities than the general population in Taiwan.

Urbanization and the utilization of outpatient services under National Health Insurance in Taiwan

OBJECTIVES

This study aims to investigate the relationship between the level of urbanization and the utilization of outpatient services under the National Health Insurance (NHI) program in Taiwan.

METHODS

We adopted a two-part model using data from the 2001 National Health Interview Survey (NHIS) and the 2001 National Health Insurance Research Database (NHIRD) in Taiwan. Data for a total of 20,640 individuals were obtained for subsequent analysis in this study.

RESULTS

The results of the first part, the contact analysis, indicate that individuals residing in areas with lower urbanization levels are less likely to use outpatient services compared to those residing in areas with the highest urbanization levels. The second part of the frequency analysis revealed that, for those individuals that had previously utilized outpatient services, those residing in areas with lower urbanization levels tended to utilize outpatient services less than individuals residing in areas with higher levels of urbanization.

CONCLUSIONS

Our empirical results show that differences between urbanization levels are a major contributory factor associated with the probability and frequency of outpatient utilization in Taiwan.

Cesarean and VBAC rates among immigrant vs. native-born women: a retrospective observational study from Taiwan Cesarean delivery and VBAC among immigrant women in Taiwan

BACKGROUND

Cultural and ethnic roots impact women's fertility and delivery preferences This study investigated whether the likelihood of cesarean delivery, primary cesarean, and vaginal delivery after cesarean (VBAC) varies by maternal national origin.

METHODS

We conducted a nation-wide, population-based, observational study using secondary data from Taiwan. De-identified data were obtained on all 392,246 singleton live births (≥500 g; ≥20 weeks) born to native-born Taiwanese, Vietnamese and mainland Chinese-born mothers between January 1, 2006 and December 31, 2007 from Taiwan's nation-wide birth certificate data. Our analytic samples consisted of the following: for overall cesarean likelihood 392,246 births, primary cesarean 336,766 (excluding repeat cesarean and VBAC), and VBAC 55,480 births (excluding primary cesarean and vaginal births without previous cesarean). Our main outcome measures were the odds of cesarean delivery, primary cesarean delivery and VBAC for Vietnamese and Chinese immigrant mothers relative to Taiwanese mothers, using multiple regression analyses to adjust for maternal and neonatal characteristics, paternal age, institutional setting, and major obstetric complications.

RESULTS

Unadjusted overall cesarean, primary cesarean, and VBAC rates were 33.9%, 23.0% and 4.0% for Taiwanese, 27.6%, 20.1% and 5.0% for mainland Chinese, and 19.3%, 13.9 and 6.1% for Vietnamese respectively. Adjusted for confounders, Vietnamese mothers were less likely than native-born Taiwanese to have overall and primary cesarean delivery (OR = 0.59 and 0.58 respectively), followed by Chinese mothers (both ORs = 0.90 relative to native-born Taiwanese). Vietnamese mothers were most likely to have successful VBAC (OR = 1.58), followed by Chinese mothers (OR = 1.25).

CONCLUSION

Immigrant Vietnamese and Chinese mothers have lower odds of cesarean and higher VBAC odds than native-born Taiwanese, consistent with lower cesarean rates prevailing in their home countries (Vietnam 10.1%; mainland China 20%-50% rural and urban respectively).