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Predictive model for the determination of caesarean sections in the Catalan National Health System: an approach based on clinical factors
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Abstract
Objective:To develop and validate a logistic regression model for analyzing the probability of caesarean section births, adjusted for clinical complexity, across public hospitals in Catalonia, and to identify deviations from expected caesarian section rates for benchmarking and quality improvement.
Methods:This retrospective cohort study analyzed data from the Catalan National Health System's Minimum Basic Data Set (CMBD-AH), including all deliveries in public hospitals from January 2018 to June 2024. A logistic regression model was constructed using maternal and obstetric factors such as age, obstetric history, and clinical conditions. The model was validated through calibration plots and receiver operating characteristic (ROC) curve analysis, achieving an area under the curve (AUC) of 0.803.
Results:The analysis revealed variability in observed-to-expected caesarean section ratios across hospital complexity levels. Level III hospitals aligned closely with expected rates, reflecting adherence to clinical standards for high-complexity cases. Level I hospitals demonstrated significant variability, with 59.1% performing more cesareans than expected; smaller hospitals with fewer than 1,000 births exhibited the greatest deviation. The model highlighted both underperforming and overperforming institutions, offering actionable insights for resource allocation and policy interventions.
Conclusions:The logistic regression model provides a robust framework for evaluating caesarean section practices, enabling fair comparisons between hospitals by adjusting for clinical complexity. It supports the identification of non-clinical factors influencing cesarean practices and offers a critical tool for quality improvement and optimizing maternal healthcare within Catalonia's public health system.
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Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%–15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so‐called “caesarian on maternal request.” These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long‐term complications and increase the chances of developing different noncommunicable diseases and immune‐related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.
Objectives
The objective of this study is to explore the association of health financing indicators with the proportion of births by caesarean section (CS) across countries.
Design
Ecological cross-country study.
Setting
This study examines CS proportions across 172 countries.
Main outcome measures
The primary outcome was the percentage excess of CS proportion, defined as CS proportions above the global target of 19%. We also analysed continuous CS proportions, as well as excess proportion with a more restrictive 9% global target. Multivariable linear regressions were performed to test the association of health financing factors with the percentage excess proportions of CS. The health financing factors considered were total available health system resources (as percentage of gross domestic product), total contributions from private households (out-of-pocket, compulsory and voluntary health insurance contributions) and total national income.
Results
We estimate that in 2018 there were a total of 8.8 million unnecessary CS globally, roughly two-thirds of which occurred in upper middle-income countries. Private health financing was positively associated with percentage excess CS proportion. In models adjusted for income and total health resources as well as human resources, each 10 per cent increase in out-of-pocket expenditure was associated with a 0.7 per cent increase in excess CS proportions. A 10 per cent increase in voluntary health insurance was associated with a 4 per cent increase in excess CS proportions.
Conclusions
We have found that health system finance features are associated with CS use across countries. Further monitoring of these indicators, within countries and between countries will be needed to understand the effect of financial arrangements in the provision of CS.
Introduction
In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth.
Methods
A retrospective, exploratory, descriptive study of an indication‐only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse‐midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5‐minute Apgar scores.
Results
Records for 1069 women cared for by nurse‐midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course.
Discussion
Indication‐only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed.
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women’s views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women’s capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
In 1985 when a group of experts convened by the World Health Organization in Fortaleza, Brazil, met to discuss the appropriate technology for birth, they echoed what at that moment was considered an unjustified and remarkable increase of caesarean section (CS) rates worldwide.1 Based on the evidence available at that time, the experts in Fortaleza concluded: ‘there is no justification for any region to have a caesarean section rate higher than 10–15%’.1 Over the years, this quote has become ubiquitous in scientific literature, being interpreted as the ideal CS rate. Although this reference range was intended for ‘populations’, which are defined by geopolitical boundaries, in many instances it has been mistakenly used as the measurement for healthcare facilities regardless of their complexity or other characteristics. In addition to the case mix of the obstetric population served, the use of CS at healthcare facilities is also affected by factors such as their capacity to handle cases, availability of resource and the clinical management protocols used locally.
Childbirth assistance in highly technological settings and existing variability in the interventions performed are cause for concern. In recent years, numerous recommendations have been made concerning the importance of the physiological process during birth. In Spain and Catalonia, work has been carried out to implement evidence-based practices for childbirth and to reduce unnecessary interventions.To identify obstetric intervention rates among all births, determine whether there are differences in interventions among full-term single births taking place in different hospitals according to type of funding and volume of births attended to, and to ascertain whether there is an association between caesarean section or instrumental birth rates and type of funding, the volume of births attended to and women's age.
Cross-sectional study, taking the hospital as the unit of analysis, obstetric interventions as dependent variables, and type of funding, volume of births attended to and maternal age as explanatory variables. The analysis was performed in three phases considering all births reported in the MBDS Catalonia 2011 (7,8570 births), full-term single births and births coded as normal.
The overall caesarean section rate in Catalonia is 27.55% (CI 27.23 to 27.86). There is a significant difference in caesarean section rates between public and private hospitals in all strata. Both public and private hospitals with a lower volume of births have higher obstetric intervention rates than other hospitals (49.43%, CI 48.04 to 50.81).
In hospitals in Catalonia, both the type of funding and volume of births attended to have a significant effect on the incidence of caesarean section, and type of funding is associated with the use of instruments during delivery.
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.
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, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model.
146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008.
Rate of caesarean sections per 100 births (live or stillborn).
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.
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.
Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too “medicalised” and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working
Until the 17th century, birth in most parts of the world was firmly in the exclusively female domestic arena, and hospital birth was uncommon before the 20th century, except in a few major cities. 1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. Instrumental delivery with forceps became the hallmark of the obstetric era. In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The introduction first of antiseptic and aseptic techniques and later of sulphonamides, coupled with changes in the severity of puerperal sepsis, lowered the maternal mortality that had made hospitals dangerous places in which to give birth.3
#### Summary points
Obstetricians play an important role in preserving lives when there are complications of pregnancy or labour
In developed countries, however, obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness
Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making
Emerging evidence suggests that higher rates of normal births are linked to beliefs about birth, implementation of evidence based practice, and team working
Maternal mortality in the West fell substantially during the 20th century. The World Health Organization and Unicef …
Squaring the Circle: Normal birth research, theory and practice in a technological age
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