Prevalence and determinants of caesarean section in a teaching hospital of Pakistan

Prevalence, indications and neonatal complications of caesarean deliveries in Cameroon: a systematic review and meta-analysis

BACKGROUND

The trend of increasing caesarean deliveries in developed countries over the past three decades is now being observed in sub-Saharan African. This rise might be associated with an increase in the complications that could arise from this surgical intervention. We therefore sought to assess the prevalence, indications and complications of caesarean deliveries in Cameroon.

METHODS

We systematically searched online databases: Medline; Global Health and the CINAHL from 01st January 1966 to 25th July 2019. We reviewed published cohort studies, retrospective register analysis and cross-sectional studies that described cohorts of pregnant women presenting at delivery facilities in Cameroon; and included those that had an estimate of the proportion of women who delivered by caesarean sections.

RESULTS

There were 126 articles initially identified by the search and 88 articles were retained after removal of duplicates. After screening of the titles and abstracts, and full text review, we identified 16 articles describing 22 cohorts of women presenting for delivery in health facilities in Cameroon. The overall estimate for the prevalence of caesarean deliveries was 9.9% (95% CI: 7.4, 12.8%, I2 = 99.68%, χ2 = 315.9, p < 0.001). The prevalence of caesarean deliveries increased progressively from 3.4% (95% CI: 2.2, 4.8%) before the year 2000, to 9.8% (95% CI: 7.4, 12.8%) between 2000 and 2009 and 14.7% (95% CI: 8.8, 21.7%) from 2010 to 2019. The three commonest indications for caesarean deliveries were: cephalopelvic disproportion (27.5%; 95% CI: 17.5, 38.7%); previous caesarean deliveries (13.2%; 95% CI: 7.4, 20.3%) and foetal distress (11.2%; 95% CI: 4.8, 19.5%). Neonates who were born by caesarean delivery were more likely to have neonatal asphyxia when compared with neonates born from vaginal deliveries (OR: 6.5; 95% CI: 2.5, 16.5).

CONCLUSION

The rates of caesarean deliveries in Cameroon falls just within the recommended 10-15% range proposed by the World Health Organisation but have however been increasing progressively in the past decades. There is a strong need to assess the various indications of caesarean deliveries in Cameroon in order to curb its associated complications.

Women's experiences of midwifery care immediately before and after caesarean section deliveries at a public Hospital in the Western Region of Ghana

Background

Childbirth remains a uniquely multifaceted, mental-cognitive and a major life experience to women. It is composed of a variety of psycho social and emotional aspects and creates memories, sometimes bad experiences and unmet expectations which leaves the mother with lasting scars. Therefore, this study aimed at exploring post-caesarean section delivered mothers experiences of midwifery care in a public hospital in Ghana.

Methods

This descriptive exploratory qualitative research used an interpretative approach to explore mothers’ experiences of midwifery care immediately before and after caesarean section (CS). The study employed a purposive sampling technique in recruiting 22 participants who had knowledge of the phenomenon under study. Data collection was guided by an interview guide, which involved face to face individual interviews and focus group discussion at the postnatal ward and clinic. All interviews were audio-recorded and lasted 30–40 min. Audio recordings were transcribed verbatim and inductive thematic data analysis employed.

Results

Four major themes emerged from the analysis of participants’ transcripts: Support by Midwives (physical and psychological, and attitude towards patients’ pain management); Protection of mothers (provision of privacy, confidentiality and physical environment); Provision of information/communication (before caesarean section, and before a minor task) and midwives’ attitude (attitude towards delivery care).

Conclusion

Mothers delivered by caesarean section had varied experiences of midwifery care which were both positive and negative ones. Provision of psychological support and adequate pain management were positive experiences. The challenges experienced were related to provision of information, privacy, and physical support. Participants, who underwent emergency CS in particular, were dissatisfied with the provision of information concerning the surgical procedure. Provision of privacy and physical support were also issues of great concern. We therefore, recommend supportive and sensitive midwifery care particularly for mothers undergoing emergency CS. Documenting women’s diverse experiences of midwifery care before and after CS delivery is important to healthcare providers, hospital managers and policy makers as the feedback garnered can be used to improve maternity services and inform decisions on midwifery care.

Socioeconomic and demographic factors associated with caesarean section delivery in Southern Ghana: evidence from INDEPTH Network member site

BACKGROUND

In recent years, caesarean section rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate caesarean section rate and the associated short- and long-term risks. This study sought to identify the rate of caesarean section and associated factors in two districts in rural southern Ghana.

METHODS

Pregnancy, birth, and socio-demographic information of 4948 women who gave birth between 2011 and 2013 were obtained from the database of Dodowa Health and Demographic Surveillance System. The rate of C-section was determined and the associations between independent and dependent variables were explored using logistic regression. The analyses were done in STATA 14.2 at 95% confidence interval.

RESULTS

The overall C-section rate for the study period was 6.59%. Women aged 30-34 years were more than twice likely to have C-section compared to those < 20 year (OR: 2.16, 95% CI: 1.20-3.90). However, women aged 34 years and above were more than thrice likely to undergo C-section compared to those < 20 year (OR: 3.73, 95% CI: 1.45-5.17). The odds of having C-section was 65 and 79% higher for participants with Primary and Junior High level schooling respectively (OR: 1.65, 95% CI: 1.08-2.51, OR:1.79, 95%CI: 1.19-2.70). The likelihood of having C-section delivery reduced by 60, 37, and 35% for women with parities 2, 3 and 3+ respectively (OR:0.60, 95% CI: 0.43-0.83, OR: 0.37, 95% CI: 0.25-0.56, OR:0.35, 95% CI: 0.25-0.54). There were increased odds of 36, 52, 83% for women who belong to poorer, middle, and richer wealth quintiles respectively (OR: 1.36, 95%CI: 0.85-2.18, OR: 1.52, 95% CI: 0.97-2.37, OR: 1.83, 95% CI: 1.20-2.80). Participants who belonged to the richest wealth quintile were more than 2 times more likely to have C-section delivery (OR: 2.14, 95%CI: 1.43-3.20). The odds of having C-section delivery reduced by 76% for women from Ningo-Prampram district (OR: 0.76, 95% CI: 0.59.0.96). Women whose household heads have Junior High level and above of education were 45% more likely to have C-section delivery (OR: 1.45, 95% CI: 1.09-1.93).

CONCLUSION

Age of mother, educational level, parity, household socioeconomic status, district of residence, and level of education of household head are associated with caesarean section delivery.

Comparison of neonatal outcomes between category-1 and non-category-1 Primary Emergency Cesarean Section: A retrospective record review in a tertiary care hospital

OBJECTIVE

To compare neonatal outcomes between Category-1 and Non-Category-1 Primary Emergency Cesarean Section.

METHODS

This was a retrospective analysis, conducted at Aga Khan University Hospital Karachi from January 1st 2016 till December 31st 2016. Non-probability purposive sampling technique was used. A sample size of 375 patients who had primary Emergency Caesarean Section (Em-CS) was identified by keeping CS rate of 41.5% and 5% bond on error. Data was collected from labor ward, operating theatre and neonatal ward records by using structured questionnaire.

RESULTS

In the current study, out of 375 participants who underwent primary Em-CS; majority (89.3%) were booked cases. Two-hundred-eighty-two (75.2%) were primiparous women. Two hundred and thirty (61.3%) were at term and 145(38.7%) were preterm. The main indication among Category-1 CS was fetal distress (15.7%). For Non-Category-1 CS, non-progress of labour (45.1%) was the leading cause of abdominal delivery. Except for APGAR score at one minute (p value = 0.048), no other variables were statistically significant when neonatal outcomes were compared among Category-1 and Non-Category-1 CS.

CONCLUSION

In this study, fetal distress and non-progress of labor were the main indications for Category-1 and Non-Category-1 CS respectively. We did not find statistically significant association between indications of Em CS and neonatal outcomes. However further prospective studies are required to confirm this association.

Frequency and evaluation of the perceptions towards caesarean section among pregnant women attending public hospitals in Pakistan and the implications

OBJECTIVES

There is increasing prevalence of caesarean sections (CS) worldwide; however, there are concerns about their rates in some countries, including potential fears among mothers. Consequently, we aimed to determine the frequency of CS, and explore patient's perception towards CS attending public hospitals in Pakistan, to provide future guidance.

METHODS

A two-phased study design (retrospective and cross sectional) was adopted. A retrospective study was conducted to assess the frequency of CS over one year among four public hospitals. A cross sectional study was subsequently conducted to determine patients' perception towards CS attending the four tertiary care public hospitals in Quetta city, Pakistan, which is where most births take place.

RESULTS

Overall prevalence of CS was 13.1% across the four hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8% perceived CS as dangerous, influenced by education (p = 0.004), locality (p = 0.001) and employment status (p = 0.001), 74.5% of patients were in agreement that this is the best approach to save mother's and baby's lives if needed. 62% of respondents reported they would like to avoid CS if they could due to post-operative pain, and 58.9% preferred a normal delivery. There was also a significant association with education (p = 0.001) and locality (p = 0.001) where respondents considered normal vaginal delivery as painful.

CONCLUSION

The overall frequency of CS approximates to WHO recommendations, although there is appreciable variation among the four hospitals. When it comes to perception towards CS, women had limited information. There is a need to provide mothers with education during the antenatal period, especially those with limited education, to accept CS where needed.

Opinions and attitudes of obstetricians and midwives in Turkey towards caesarean section and vaginal birth following a previous caesarean section

Aim

To determine the opinions and attitudes of Turkish obstetricians and midwives to caesarean section (C-section) and vaginal birth following a C-section.

Methods

The study involved obstetricians and midwives who were working in a state women’s hospital and two private hospitals in Gaziantep, Turkey. Participants were asked to complete questionnaires on sociodemographic data and provide opinions about C-section.

Results

A total of 88 midwives and 22 obstetricians participated in the study. Approximately one-third of midwives believed caesarean rates were high at their institution and more than 50% thought that the rate should be reduced. In contrast, although approximately 80% of obstetricians thought that caesarean rates in their institutions ranged between 25–50%, only 18% believed the rate was high and 68% believed that the rate of should be reduced. Midwives and obstetricians tended to agree on most suggested reasons for high C-section rates. When asked about interventions that may reduce the C-section rates, midwives and obstetricians had opposing views. However, most participants agreed that prenatal childbirth preparation courses would be beneficial.

Conclusions

This study showed that most midwives and obstetricians believe the rate of C-section at their institution is high and should be reduced.

Comparing Performance Indicators of Obstetrics and Gynecology Ward at Yazd Educational Hospitals with Expected Limits of Indicators, 2015

Objectives

The purpose of this study was to evaluate the performance indicators for obstetrics and gynecology wards in Iran.

Methods

This study was designed as a cross-sectional study and was carried out in obstetrics and gynecology wards of Afshar and Shahid Sadoughi hospitals in 2015. The information required for the performance indicators was gathered through questionnaires, statistical forms, and direct observation. In several tables, performance rating and performance status are presented using the Likert scale index based on the expected limits.

Results

According to the results of the categories of input indicators, the bed occupancy rate of Afshar Hospital’s obstetrics and gynecology ward was, at 83%, higher than expected (79%), and that in Shahid Sadoughi Hospital (at 69%) was lower than expected. For medicinal methods and nonmedicinal methods of pain alleviation, the index process at Afshar Hospital was much lower than expected (40%). In Afshar Hospital, patient satisfaction at discharge was about 66.74%.

Conclusion

Effective steps can be taken to improve the input and output criteria: allocating appropriate physical space, examining the reasons for low bed occupancy rate by using complex analytical models, and in order to study the reasons for large number of cesarean section childbirth, it was recommended to place more emphasis on training of pregnant mothers and to inform them about the side effects of cesarean section and advantages of natural childbirth.

Evaluation of Clinical Diagnosis of Fetal Distress and Perinatal Outcome in a Low Resource Nigerian Setting

INTRODUCTION

Fetal distress has been shown to contribute to the increasing caesarean section rate. There has been controversy on the usefulness of clinical diagnosis of fetal distress using only the intermittent counting of the fetal heart rate and/or passage of meconium-stained liquor.

AIM

To evaluate the clinical diagnosis of fetal distress and the perinatal outcome.

MATERIALS AND METHODS

This was a retrospective study in which the case records of the patients, who were diagnosed of fetal distress at Federal Teaching Hospital, Abakaliki, Nigeria, from January 1, 2008 to December 31, 2014, were collated. The statistical analysis was done using the Statistical Package for Social Sciences version 17 software (SPSS Inc., Chicago IL, USA).

RESULTS

Out of the 15,640 deliveries carried out within the study period, 3,761 (24.05%) deliveries were through caesarean section. A total of 326 (8.9%) of the 3,761 caesarean sections were due to fetal distress within the study period. More so, a total of 227 (70.9%) babies were born with ≥ 7 Apgar score at the 1(st) minute of delivery. The perinatal mortality rate was 31.25 per 1000 deliveries. Though birth asphyxia was recorded more on babies of mothers that had fresh meconium-stained liquor and whose decision-intervention interval was more than 30 minutes when compared with those without any of the two conditions, there was no statistical significant difference between them.

CONCLUSION

The clinical diagnosis of fetal distress is accurate in 29.1% of the cases. However, it has led to an unnecessary caesarean section in the remaining 70.9% of the parturients. In order to reduce this high trend of unnecessary caesarean sections due to clinical diagnosis of fetal distress in this environment, antepartum fetal assessment with non-stress test or biophysical profile and intrapartum use of continuous electronic fetal monitoring should be used to confirm or refute the fetal distress before any surgical intervention. Fetal blood sampling and fetal pulse oximetry should be performed in event of non- re-assuring or abnormal cardiotocography.

Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review

Background

Cesarean section is the commonest obstetric operative procedure worldwide. When used appropriately cesarean sections can improve infant and/or maternal outcomes. However, when used inappropriately the potential harm may exceed the potential benefit of cesarean section. Appreciating the limited information in this area the current study assessed the rate and factors associated with cesarean section in Felegehiwot referral hospital, Bahir Dar, northwest Ethiopia.

Method

The study was a retrospective analysis of eligible patient records that included 2967 pregnant women who had underwent either cesarean or vaginal delivery from July 1, 2012 to June 31, 2013. The data were double entered to EPI-INFO 3.5.2 and analyzed with SPSS. Binary logistic regression model was fitted to identify independent factors associated with cesarean section.

Result

The proportion of women who underwent cesarean section in this study was 25.4 %. Obstructed labor (30.7 %), fetal distress (15.9 %) and abnormal presentation (13.4 %) were the major obstetric indications for cesarean section. The odd of undergoing cesarean section was higher among mothers in rural residence (AOR = 1.63, 95 % CI: 1.21, 2.20), mothers reported to have pregnancy risk factors (AOR = 2.31, 95 % CI: 1.74, 3.07) and lower among mothers in age category of 15–19 (AOR = 0.63, 95 % CI: 0.43, 0.93).

Conclusion

Obstetric factors occurring around birth, including obstructed labor and fetal distress were the main reasons leading to Cesarean Section rather than background characteristics assumed to be a risk. The results imply that there is a need for timely and accurate screening of women during obstetric care and, decision to perform cesarean section should be based on clear, compelling and well-supported justifications.

Investigation of long- and short-term relationships between cesarean delivery and its effective factors in Malayer

Introduction:

Recently, there has been significant increase in the number of operated cesarean compared to the overall number of birth giving. There are several factors affecting the operated cesarean in Iran compared to the birth giving which are to be reviewed in this study.

Procedure:

The data of the study has been obtained from the registered information in Assistance Section of Health at Hamedan Faculty of Medicine which includes the seasonal data having to do with giving birth of Malayer since the beginning of Winter 2006 to the end of Fall 2013. The assimilation techniques, namely ARDL method and Error Correction Method (ECM) are the main methods to be used in this study.

Results:

The short-term and long-term coefficients of abnormal view, incongruent status of fetus and pelvis, lack of progression, and the lengthy status are considered significant statistically. The ecm coefficient is -1.3456 in short-term. Also, his coefficient is significant which shows the short-term balance trend to the long-term one.

Conclusion:

The most indispensable affective factor on demanding to run the cesarean operation in short-term and long-term in Malayer are the lengthy-status, lack of progression, abnormal view, and incongruent status of fetus and pelvis, respectively.

Caesarean section--an appraisal of some predictive factors in Lagos Nigeria

Background

Several maternity units in the developing world lack facilities for caesarean section and often have to transfer patients in extremis. This case controlled study aimed to appraise predictive factors for caesarean section.

Methods

One hundred and fifty two consecutive women with singleton pregnancies who had caesarean section were studied. The next parturient with normal delivery served as control. Variables such as age, parity, marital status, booking status, past obstetric history, weight, height, infant birth weight were assessed. Data obtained were analysed using SPSS 16.0 Windows package.

Results

During the study period, there were 641 deliveries with 257 of them by caesarean section (40.1%).

Logistic regression analysis showed that parity, booking status, maternal height; maternal weight, birth weight, previous caesarean section and ante-partum bleeding were significant predictive factors for caesarean section while maternal age was not.

Conclusions

These predictive factors should be considered in antenatal counseling to facilitate acceptance by at risk women and early referral.

Package of care for active management in labour for reducing caesarean section rates in low-risk women

BACKGROUND

Approximately 15% of women have caesarean sections (CS) and while the rate varies, the number is increasing in many countries. This is of concern because higher CS rates do not confer additional health gain but may adversely affect maternal health and have implications for future pregnancies. Active management of labour has been proposed as a means of reducing CS rates. This refers to a package of care including strict diagnosis of labour, routine amniotomy, oxytocin for slow progress and one-to-one support in labour.

OBJECTIVES

To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (16 April 2013).

SELECTION CRITERIA

Randomised controlled trials comparing low-risk women receiving a predefined package of care (active management) with women receiving routine (variable) care. Trials where slow progress had been diagnosed before entry into the trial were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data. We assessed included studies for risk of bias.

MAIN RESULTS

We included seven trials, with a total of 5390 women. The quality of studies was mixed. The CS rate was slightly lower in the active management group compared with the group that received routine care, but this difference did not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). However, in one study there was a large number of post-randomisation exclusions. On excluding this study, CS rates in the active management group were statistically significantly lower than in the routine care group (RR 0.77 95% CI 0.63 to 0.94). More women in the active management group had labours lasting less than 12 hours, but there was wide variation in length of labour within and between trials. There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care.

AUTHORS' CONCLUSIONS

Active management is associated with small reductions in the CS rate, but it is highly prescriptive and interventional. It is possible that some components of the active management package are more effective than others. Further work is required to determine the acceptability of active management to women in labour.

The boom in unnecessary caesarean surgeries is jeopardizing women's health

High caesarean birth rates present an issue of international public health concern. We explore the prevalence and sociodemographic maternal factors associated with cesarean-section births among 272 mothers with children under 5 years old in an urban community of central India. In this population-based, cross-sectional study, we learned that the prevalence of cesarean section was unacceptably high and significantly higher in those deliveries that were either preterm/ post-term, amongst mothers who had delivered at a private hospital, and among mothers with higher socioeconomic status. A third of the mothers reported lumbar back pain and almost 90% felt that the expenditure for cesarean sections is not reasonable.

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.

Twin pregnancies in the Niger Delta of Nigeria: a four-year review

Background

The female is programmed to nurture one fetus and to take care of one neonate at a time; hence, twin pregnancy is associated with an increased risk of preterm deliveries, perinatal morbidity, and mortality and maternal complications. This study aimed to determine the twinning rate, and maternal and fetal outcomes of all twin pregnancies managed at the Niger Delta University Teaching Hospital Okolobiri.

Methods

The study is a 4-year descriptive retrospective evaluation of twin pregnancies managed at the Niger Delta University Teaching Hospital Okolobiri. Records of all pregnancies, booked and unbooked, managed from January 1, 2007 to December 31, 2010 were reviewed. Details of delivery and maternal and fetal outcomes were obtained using a pro forma designed for the study. Epi Info version 3.5.3 was used for statistical analysis. The Chi-square test was used to test for associations between variables. The level of significance was set at P ≤ 0.05.

Results

A total of 1341 deliveries including 41 cases of twin deliveries were recorded during the study period, giving an incidence of 30.6/1000. Twenty-nine (70.7%) of the patients were unbooked. The mean gestational age was 33.3 ± 2.6 weeks, and the mean fetal weight was 2.34 ± 0.54 kg. There were 13 perinatal deaths, with a perinatal mortality rate of 158.5/1000. There was no association between booking status and perinatal mortality rate (χ² = 0.017, P = 1.000). Prematurity was the chief cause of perinatal death (65.4%). Maternal morbidities included anemia, wound infection, and genital sepsis. There were no maternal deaths.

Conclusion

The twinning rate was high. There was a high perinatal mortality rate, with prematurity accounting for most of the mortality. There is a need for improved incubation/neonatal care for better outcomes with twin pregnancies in the hospital.

Package of care for active management in labour for reducing caesarean section rates in low-risk women

BACKGROUND

Approximately 15% of women have caesarean sections (CS) and while the rate varies, the number is increasing in many countries. This is of concern because higher CS rates do not confer additional health gain but may adversely affect maternal health and have implications for future pregnancies. Active management of labour has been proposed as a means of reducing CS rates. This refers to a package of care including strict diagnosis of labour, routine amniotomy, oxytocin for slow progress and one to one support in labour.

OBJECTIVES

To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2008), MEDLINE (1966 to December 2007), EMBASE (1980 to 2007), MIDIRS (1985 to 2007) and CINAHL (1982 to 2007).

SELECTION CRITERIA

Randomised controlled trials comparing low-risk women receiving a predefined package of care (active management) with women receiving routine (variable) care. Trials where slow progress had been diagnosed before entry into the trial were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data. We assessed included studies for risk of bias.

MAIN RESULTS

We included seven trials, with a total of 5390 women. The quality of studies was mixed. The CS rate was slightly lower in the active management group compared to the group that received routine care, but this difference did not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). However, in one study there was a large number of post-randomisation exclusions. On excluding this study, CS rates in the active management group were statistically significantly lower than in the routine care group (RR 0.77 95% CI 0.63 to 0.94). More women in the active management group had labours lasting less than twelve hours, but there was wide variation in length of labour within and between trials. There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care.

AUTHORS' CONCLUSIONS

Active management is associated with small reductions in the CS rate, but it is highly prescriptive and interventional. It is possible that some components of the active management package are more effective than others. Further work is required to determine the acceptability of active management to women in labour.

Decision aids for women with a previous caesarean section

Focusing on women's preferences improves decision making

How much variation in CS rates can be explained by case mix differences?

OBJECTIVE

To quantify the amount of variation in caesarean section (CS) rates between maternity units explained by case mix differences.

DESIGN

Cross-sectional study.

SETTING

All 216 maternity units in England and Wales.

POPULATION

Women giving birth at these maternity units between May and July 2000.

METHODS

Logistic regression models were developed to investigate the relationship between case mix characteristics, and odds of (i) CS before labour, (ii) CS in labour. Using these results, overall CS rates standardised for case mix were calculated for each maternity unit. Random-effects meta-analysis was used to examine heterogeneity between maternity units.

MAIN OUTCOME MEASURES

CS before labour and CS during labour.

RESULTS

Adjustment for case mix differences between maternity units explained 34% of the variance in CS rates. Odds of CS (before and in labour) increased with maternal age. Women from ethnic minority groups had lower odds of CS before labour, and increased odds of CS in labour. Women with a previous vaginal delivery had lower odds of CS, although the magnitude of this for CS before and in labour is markedly different.

CONCLUSIONS

Case mix adjustment is important to enable understanding of the factors that influence the CS rate. These include organisational and staffing levels as well as women's preferences for childbirth and clinician's attitudes. An understanding of how these factors influence the CS rate is essential for evaluation of quality and appropriateness of obstetric care provided to women.