Hospital differences in rates of cesarean deliveries in the Sardinian region: An observational study

Background: The rates of cesarean deliveries have been increasing steadily in several European\r\ncountries in recent decades, with Italy having the second-highest rate (38% in 2010), causing concern\r\nand debate about the appropriateness of many interventions. Moreover, some recent studies suggest\r\nthat rates of common obstetric interventions are not homogeneous across hospitals, maybe not only\r\nbecause of patient case mix but also possibly because of different hospital practices and cultures.\r\nThus, it is important to investigate whether the variation in rates of cesarean sections can be traced\r\nback to patient characteristics or whether it depends upon context variables at the hospital level.\r\nMethods: Using official hospital abstracts on deliveries that occurred in Sardinia over a two-year\r\nperiod, we implement multilevel logistic regression models in order to assess whether the observed\r\ndifferences in cesarean rates across hospitals can be justified by case-mix differences across hospitals.\r\nResults: The between-hospital variation in rates of cesarean delivery is estimated to be 0.388 in\r\nthe model with only the intercept and 0.382 in the model controlling for the mother’s clinical and\r\nsociodemographic characteristics.\r\nConclusionS: The results show that taking into account the individual characteristics of delivered\r\nmothers is not enough to justify the observed variation across hospital rates, suggesting the important\r\nrole of unobserved variables at the hospital level in determining cesarean section rates.