Institutional factors associated with cesarean section rates in hospitals of Mexico. Author: Conzuelo-Rodriguez G.1 Advisor: Lisa M. Bodnar1 Internship 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.

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.

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.

Objective. The aim of this study is to evaluate the association between obstetric institutional capacity and CS rate in a Mexican setting.

Data 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 Robson classification

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)

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.

Statistical analysis. FCI Score CS rates Multi-level logistic regression. FCI Score CS rates Secondary predictors: - Ownership - Teaching facility - Maternity exclusive

Table 1. Maternal sociodemographic characteristics. Overall (n=12,720) Robson 1a (n=3,286) Robson 2b (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 years 2,442 (21.2) 495 (16.1) 1,073 (31.9) 7-9 years 4,591 (40.0) 1,265 (41.0) 1,379 (40.9) > 10 years 4,149 (36.1) 1,246 (40.4) 829 (24.6) Missing 306 (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(%) Single 1,740 (15.2) 711 (23.1) 281 (8.3) Married or cohabitating 9,748 (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.

Table 2. Association between FCI score and CS rates a Crude Model 1b Model 2c 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 ownership 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).

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 ownership 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).

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.

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.

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.