Exploring the Impact of Indication on Differences in Rates of Emergency Caesarean Section in Six Palestinian Hospitals: a Prospective Cohort Study

Abstract BackgroundCaesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5% to 35.6%. Our aim was to assess whether differences in odds for emergency caesarean section in six Palestinian government hospitals can be explained by differences in indications.MethodsData on maternal and fetal health was collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for emergency caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square.ResultsOut of 51,041 women, 4724 (9.3%) underwent emergency caesarean section. The prevalence of emergency caesarean section varied across hospitals; from 7.6% to 22.1% in primiparous, and from 5.8% to 14.1% among parous women. The most common indications were fetal distress and failure to progress in primiparous, and previous caesarean section in parous women. Adjusted ORs for emergency caesarean section among primiparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40-0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58% and 66% of the variation in emergency caesarean section among primiparous and parous women, respectively. ConclusionThe differences in odds for emergency caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.