C-Sections Relative to Hospital Size a Cesarean

¶ … C-Sections Relative to Hospital Size

A cesarean section, more commonly known as a C-section, is a surgical procedure in which a fetus is delivered via a hysterotomy rather than a more typical vaginal delivery procedure. There are many medical reasons why a c-section is necessary, although the geographic and demographic distribution of c-sections shows many trends in the prevalence of the procedure, indicating medical necessity is not the only reason that the surgery is performed. Affluence and medical availability and infrastructure have clear impacts on the rate and outcome of c-sections.

In 2010, the World Health Organization estimated that on average, 10-15% of live births were via c-section, and the rate of c-sections in the United States, despite a rising popularity of alternative birthing methods (midwifes, home births, doulas, etc.), the c-sections have increased by 48% since 1996. While the size of hospitals studied when studying c-section outcomes has been noted, analysis is lacking on the data collected to determine c-section outcomes relative to the size of the hospital.

What was the hypothesis?

The hypothesis in the study by Kritchevsky et al., published in the American Journal of Obstetrics and Gynocology was that due to lack of standardized definitions and performance measurement systems, comparative study of c-sections across different hospitals was not fully possible. The study by Lagrew et al., was designed to examine delivery statistics obtained from a cesarean section reduction program conducted in a private hospital. The authors hypothesized that this program had been successful in reducing the number of c-sections within the hospital.

A strong study (Chen et al. 2008) using a large sample number and thorough quantitative analysis could serve as a useful model for studying the impact of urbanization and population density upon the rate of cesarean deliveries. Are c-section deliveries, which are faster, seen more often in urban hospitals with a large demand for birthing space? A large-scale study in Taiwan published in 2007 examines association.

The authors' hypothesized that there was a positive association between the degree of urbanization in Taiwan and the likelihood of a Cesarean section for the delivery of a single fetus.

What study design was implemented (cohort, case control, cross-sectional etc.)?

The study by Kritchevsky et al. (1996) looked at outcomes based on retrospective data abstraction of 200 deliveries at each of 15 acute care hospitals, including two foreign institutions. The second study (Lawgrew et al.) employed retrospective analysis of data obtained from a c-section reduction program conducted within the same institution.

The third study was a retroactive analysis of 200,207 singleton deliveries in Taiwan using information from the Taiwan 2004 National Health Insurance Research Database. The urbanization level of the mother's home area was classified into 7 categories. The data was examined with a multilevel logistic regression model to show the assocation of urbanization with rate of c-section (Chen 2008).

What are the types/classification of the variables?

The Kritchevsky et al. (1996) study investigated the differences between hospitals' c-section data and compared adjusted and unadjusted risk rates in order to examine the differences between the various tools and measures each hospital individually uses for its internal data collection and analysis. The 2008 study by Chen et al. was a retroactive analysis of 200,207 singleton deliveries in Taiwan using information from the Taiwan 2004 National Health Insurance Research Database. The urbanization level of the mother's home area was classified into 7 categories. The data was examined with a multilevel logistic regression model to show the association of urbanization with rate of c-section. The explanatory variable was the rate of urbanization while the response variable was the likelihood of c-section delivery.

The study by Lagrew et al. (1996) was designed to look at the change in c-section delivery rates over time. While the introduction of the new laboring guidelines employed by the hospital for the purposed of this study constitute a form of clinical trial, all persons in labor at the institution received the same care. The independent variable in this instance was on change over time, based on data collected in the months before and after the program was implemented. The group who received the newer standards of care were not concurrent to the group who had given birth prior to the new standards being implemented. This does introduce the lack of standardization around timing. Perhaps there were political, cultural or historical factors, which influenced the rate of c-section delivery beyond the effect of the hospital program being studied.

A literature review published in a 2007 issue of Birth indicate that sociological and cultural factors were significant influential factors in women's stated preference for c-section deliveries (McCourt 2007). Given the spread of data over a 12-month period of time, it is entirely possible that various influential factors were more or less present in the two populations observed for this study.

How were the variables operationalized?

Figure 1 in the study (Kritchevsky et al. 1996) demonstrates the way in which the variables were operationalized by normalizing data using various instruments into a relatively comparable measure. The process of standardizing the measures assisted in defining the variables further by indicating the types and degree of difference between individual institution's measures. The variables in the Lagrew et al. (1996) study were easily operationalized due to the fact that this was a study that was done retrospectively to determine if the implemented changes had the desired effect on the rates of c-section deliveries in the hospital.

The variables in the third study (Chen et al. 2008) were operationalized by deciding upon a 7 point scale of urbanization. The creation of categorical variables allowed for results ordered in an easily-understood gradient rather than using a more abstract instrument for measuring urbanization. The operationalization of c-section rates was in accordance with standard definitions used in published literature.

Were the instruments validated (i.e. against measures obtained using a different instrument)?

The retrospective data analysis methodology made validation in the study published by Krichevsky et al. 1996 impossible, as many different measures were used by the hospitals in the process of their own data collection. This article looking at hospital performance and Cesarean section rates looked explicitly at hospital sizes, among other criteria, focused predominantly on medium and large-sized medical facilities -- with an average of 537 beds -- in the United States. The size of the hospital can have some indication on the level of care provided at the facility, but smaller facilities specializing in neonatal care exist. This study was looking at facilities offering comprehensive medical services, but within the domain of tertiary medical services, more than half of the facilities studied had neonatal intensive care units.