Staffing and the determinants of caesarean sections in the English NHS (original) (raw)
Related papers
BMJ, 2010
Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. 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, socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, 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 620 604 singleton births, 147 726 (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.
The timing of elective caesarean delivery between 2000 and 2009 in England
BMC Pregnancy and Childbirth, 2011
Background: In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries.
BMJ Open
IntroductionChoice of birth setting is important and it is valuable to know how reconfiguring available settings may affect midwifery staffing needs. COVID-19-related health system pressures have meant restriction of community births. We aimed to model the potential of service reconfigurations to offset midwifery staffing shortages.MethodsWe adapted the Birthrate Plus method to develop a tool that models the effects on intrapartum and postnatal midwifery staffing requirements of changing service configurations for low-risk births. We tested our tool on two hypothetical model trusts with different baseline configurations of hospital and community low-risk birth services, representing those most common in England, and applied it to scenarios with midwifery staffing shortages of 15%, 25% and 35%. In scenarios with midwifery staffing shortages above 15%, we modelled restricting community births in line with professional guidance on COVID-19 service reconfiguration. For shortages of 15%,...
BMC Public Health, 2011
Background: Caesarean section rates have risen over the last 20 years. Elective Caesarean section rates have been shown to be linked to area deprivation in England, women in the most deprived areas were less likely to have an elective section than those in the most affluent areas. We examine whether individual social class, area deprivation or both are related to Caesarean sections in Scotland and investigate changes over time. Methods: Routine maternity discharge data from live singleton births in Scottish hospitals from three time periods were used; 1980-81 (n = 133,555), 1990-91 (n = 128,933) and 1999-2000 (n = 102,285). Multilevel logistic regression, with 3 levels (births, postcode sector and Health Board) was used to analyse emergency and elective Caesareans separately; analysis was further stratified by previous Caesarean section. The relative index of inequality (RII) was used to assess socioeconomic inequalities.
BMC Health Services Research, 2011
Background: There has been a marked increase in the number of Caesarean sections in many countries during the last decades. In several countries, Caesarean sections are carried out in more than 20 per cent of births. These high Caesarean section rates give cause for concern, both from an economic and a medical perspective. A general opinion among epidemiologists is that the increase in the number of Caesarean sections during the last decade has been greater than could be expected in relation to medical risk factors. Therefore, other explanations must be sought. We studied one potential explanation; the effect that the increase in hospital revenue per bed during the period 1976-2005 has had on the Caesarean section rate in Norway. During this period, hospital revenue increased by about 260% (adjusted for inflation). Methods: The analyses were carried out using data from the Medical Birth Registry 1976-2005 from Norway. The data were merged with data about hospital revenue, which were obtained from Statistics Norway. The analyses were carried out using annual data from 46 hospitals. A fixed effect regression model was estimated. Relevant medical control variables were included. Results: The elasticity of the Caesarean section rate with respect to hospital revenue per bed was 0.13 (p < 0.05). This represents an increase in the Caesarean section rate from the basis year 1976 to the final year 2005 of about 35 per cent. Most of the variables measuring characteristics of the health status of the mother and child had the expected effects. Conclusion: The increase in hospital revenue explains only a small part of the increase in the Caesarean section rate in Norway during the last three decades. The increase in the Caesarean section rate is considerably greater than could be expected, based on the increase in hospital revenue alone. The strength of our study is that we have estimated a cause and effect relationship. This was done by using fixed effects for hospitals, a lagged revenue variable and by including an extensive set of control variables for the risk factors of the mother and the baby.
Unexplained variation in hospital caesarean section rates
The Medical Journal of Australia, 2014
Objective: Concern over rising caesarean rates has focused attention on initiatives to reverse this trend. We assessed variation in caesarean rates among hospitals to identify potential targets for intervention. Design, Setting and Participants: This is a population-based, record linkage study of 183,310 births in 81 hospitals in New South Wales, 2009-2010. The Robson classification was used to categorise births into 10 risk-based groups based on parity, plurality, labour onset, previous caesarean, fetal presentation and gestation. Multilevel logistic regression was used to examine variation in hospital caesarean rates within Robson groups, adjusted for differences in maternal age, country of birth, smoking, diabetes, hypertension and type of maternity care. The 20 th centile ("best practice" rate) of the risk-adjusted rates was used to quantify the potential impact on the overall caesarean rate of reducing practice variation. Main outcome measures: Hospital caesarean rates Results: The overall caesarean rate was 30.9%, ranging from 11.8% to 47.4% among hospitals. Women with previous caesareans (36.4% of all caesareans) and nulliparous term births (induction or pre-labour caesarean 23.4%, spontaneous 11.1%) were the greatest contributors to the overall rate. After adjustment, marked unexplained variation in hospital caesarean rates persisted for: nulliparae at term, previous caesareans, multi-fetal pregnancies and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by 3.1%. Conclusion: Understanding hospital heterogeneity in performing caesarean sections and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in caesarean rates.
Searching for the Optimal Rate of Medically Necessary Cesarean Delivery
Birth, 2014
Background: Internationally, repeat caesarean sections (Robson Classification Group 5) make the single largest contribution to overall caesarean section rates and hospital-to-hospital variation has been reported. It is unknown if case-mix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity. Methods: This population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included all maternities with prior caesarean section that were singleton, cephalic and at term. Multilevel regression models were used with primary outcomes of 'planned repeat caesarean section' and 'intra-partum caesarean section'. The associations between quintiles of risk-adjusted hospital rates of planned and intra-partum repeat caesarean sections and case-mix adjusted maternal and neonatal morbidity rates, postpartum haemorrhage rates and Apgar score below 7 at five minutes rates were also assessed. Results: Of 61894 maternities with a prior caesarean section in 81 hospitals, 82.1% resulted in a repeat caesarean section and 17.9% in vaginal birth. Of the caesarean sections, 72.7% were planned and 9.4% were unplanned intra-partum. Crude hospital rates of planned caesarean sections ranged from 50.7% to 98.4%. Overall 49.0% of between-hospital variation in planned repeat caesarean section rates was explained by patient characteristics (17.3%) and hospital factors (31.7%). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between quintiles of planned repeat caesarean section and adjusted morbidity rates. Crude rates of intra-partum caesarean section ranged from 12.9% to 71.9%. In total, 27.5% of between hospital variation in rates of intra-partum caesarean section was explained by patient (19.5%) and hospital factors (8.0%). The adjusted morbidity rates differed among quintiles of hospital intra-partum caesarean section rates, but were influenced by a few hospitals with outlying rates. 3 Conclusions: About half of the variation in hospital planned repeat caesarean section rates was explained and strategies aimed at modifying these rates should not affect morbidity rates. Intrapartum caesarean sections were associated with morbidity but not in a systematic manner.