Author ConzueloRodriguez G 1 Advisor Lisa M Bodnar 1 Internship Preceptor OrtízPanzo E 2 CruzHernández A 2 1 University of Pittsburgh Graduate School of Public Health Pittsburgh PA EU ID: 545378
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Slide1
Institutional factors associated with cesarean section rates in hospitals of Mexico.
Author: Conzuelo-Rodriguez G.1Advisor: Lisa M. Bodnar1Internship Preceptor: Ortíz-Panzo E.2, Cruz-Hernández A.2
1. University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, EU.
2. National Institute of Public Health, Cuernavaca,
Mor
, Mexico.Slide2
Why this matters?
Cesarean section (CS) rates are increasing.Developing nations contribute the most to this rise.The elective procedures are most prevalent.
Risks overpass the benefits when done indiscriminately.Slide3
What is the problem?
Election of CS must rely upon specific medical indications exclusively.Patient, provider and institutional factors have been associated with a greater risk for CS. The role of institutional factors on CS
have not been widely explored. Slide4
Objective.
The aim of this study is to evaluate the association between obstetric institutional capacity and CS rate in a Mexican setting. Slide5
WHO Multi-country survey on maternal and newborn health
Wave 2010-2012
29 Countries
359 Facilities
> 300,000 Obstetric events
Data from Mexico
2 States
14 Facilities
13,060 Obstetric events
Data
Robson classificationSlide6
Robson classification
Categorize obstetric population into 10 mutually exclusive groups according to:Parity and previous CS.Gestational age.Onset of labor.
Fetal presentation.
Number of fetuses.
Permit
analysis on CS low risk groups
(R1 and R3)Slide7
Institutional capacity.
Facility Capacity Index (FCI).Measures 6 categories, range: 12-57 points.Standard of building/ basic services.Medical services.
Emergency obstetric services.
Laboratory tests services.
Hospital practices.
Human resources
.Slide8
Statistical analysis.
Multi-level logistic regression.FCI Score
CS rates
Secondary predictors:
- Ownership
- Teaching facility
- Maternity exclusiveSlide9
Table 1. Maternal sociodemographic characteristics.
Characteristic
Overall
(n=12,720)
Rob
son
1
a
(n=3,286)
Robson 2
b
(n=3,281)
Age n(%)
< 20 years
2,824 (24.6)
1,547 (50.2)
386 (11.4)
20-34
years
7,403 (64.4)
1,463 (47.5)
2,549 (75.6)
>
34 years
1,261 (11.0)
73 (2.3)
438 (13.0)
Education n(%)
<
6 years2,442 (21.2)495 (16.1)1,073 (31.9) 7-9 years4,591 (40.0)1,265 (41.0)1,379 (40.9) > 10 years4,149 (36.1)1,246 (40.4)829 (24.6) Missing306 (2.7)77 (2.5)92 (2.7)Nulliparous n(%)4,869 (42.4)3,083 (100)--Previous CS n(%)2,160 (18.8)----Marital status n(%) Single1,740 (15.2)711 (23.1)281 (8.3) Married or cohabitating9,748 (84.8)2,372 (76.9)3,092 (91.7)
a
Nulliparous, singleton, cephalic presentation, ≥ 37 weeks of gestation, spontaneous labor.
b
Multiparous, no prior CS, singleton, cephalic presentation, ≥ 37 weeks of gestation, spontaneous labor.Slide10
Table 2. Association
between FCI score and CS rates
a
Crude
Model 1
b
Model 2
c
Predictors
OR [95% CI]
FCI
Score
0.93 (0.87-0.98)
0.94 (0.88-0.99)
0.93 (0.75-1.15)
Private
o
wnership
3.86 (1.17-12.74)
3.20 (1.08-9.44)
1.49 (0.23-9.52)
Teaching status
0.39 (0.14-1.12)
0.48 (0.18-1.21)
0.36 (0.11-1.16)
Maternity
exclusive
0.62 (0.20-1.92)
0.63 (0.23-1.70)
0.54
(0.24-1.20)a Based on overall obstetric events (n= 12,720).b Adjusted for age, education, marital status, fetus presentation, weeks of gestation, multiple pregnancy, chronic hypertension, preeclampsia, multiple organ dysfunction and other serious conditions (placenta previa, abruptio placentae, HIV and renal disease).c Additionally adjusted for other institutional characteristics (number of beds, proportion of women receiving free of charge treatment, hospital going under audits, hospital adherence to local and/or WHO guidelines, obstetrician availability).Slide11
Table 2. Association
between FCI score and CS rates among low risk groups defined as either Robson 1
a
or Robson 3
b
.
Overall
c
(n= 12,720)
Low risk group
c
(n= 6,567)
Predictors
OR [95% CI]
FCI
Score
0.94 (0.88-0.99)
0.96 (0.89-1.04)
Private
o
wnership
3.20 (1.08-9.44)
1.74 (0.46-6.52)
Teaching status
0.48 (0.18-1.21)
0-72 (0-24-2.16)
Maternity
exclusive
0.63 (0.23-1.70)
0.57 (0.19-1.64)
a Nulliparous, singleton, cephalic presentation, ≥ 37 weeks of gestation, spontaneous labor.b Multiparous, no prior CS, singleton, cephalic presentation, ≥ 37 weeks of gestation, spontaneous labor.c Adjusted for age, education, marital status, fetus presentation, weeks of gestation, multiple pregnancy, chronic hypertension, preeclampsia, multiple organ dysfunction and other serious conditions (placenta previa, abruptio placentae, HIV and renal disease).Slide12Slide13
Results.
CS is more frequently performed among low capacity hospitals in Mexico.Private hospitals in our sample.In those less prepared hospitals, the majority of CS showed no evidence of labor.Slide14
Discussion.
Data from National Survey of Health and Nutrition, Mexico (ENSANUT 2012) reported higher proportion of CS in private hospitals.Revenue for physicians and facilities.Women’s belief that CS is better and safer for their children.Slide15
A final note.
Current regulations must be enforced in order to limit CS to necessary cases only.Final decision must always be individualized according to fetal and maternal characteristics.