[Impact of organizational factors on the cesarean delivery occurrence in a low-risk population]

Huge differences in cesarean delivery rate exist between maternities in a same region. In recent years, the cesarean delivery rate has increased in the low-risk population. The objective of this study was to assess the impact of organizational factors on the cesarean delivery occurence in a low-risk population.

We performed a population-based cohort study in the MYPA perinatal network from 2009 to 2015. A low-risk population was selected, keeping only groups 1 and 3 of the Robson classification. The studied organizational factors included the structural characteristics of maternity (academic or not, public or private, number of annual births, maternal intensive care unit, neonatal intensive care unit, number of delivery rooms) and the organization of the health care team (number of midwives and obstetricians, on call duty, workload and implementation of a morbi-mortality review). We used a logistic multilevel model, based on random center effect, for both univariable and multivariable analysis.

Our study population included 64,100 women. The cesarean delivery rate ranged from 5.5 to 11.3 % among the 10 maternities. In univariate analysis, the organizational variables significantly associated with the cesarean delivery rate were maternity status (university hospital, non-university public hospital and private hospital) and the implementation of a morbi-mortality review. However, after adjustment, none of these organizational factors were significantly associated with the cesarean delivery occurence. When multivariate analysis was restricted to the nulliparous subgroup, the private status of maternity was significantly associated with a higher rate of cesarean deliveries (OR=1.39 [1.09-1.76]). Also, the probability of cesarean delivery was higher when the number of births by delivery room increased (OR=1.15 [1.01-1.31]). For the multiparous subgroup, no variable was significantly associated with cesarean delivery occurence.

In our global low-risk population, no organizational factors appeared to be associated with an increase in cesarean delivery rate. On the other hand, in the low-risk nulliparous population, the private status of the maternity and a high number of births by delivery room were associated with more cesarean deliveries. Increasing the number of delivery rooms could be a way to reduce the number of cesarean deliveries. Future researches should also try to identify specific factors that can reduce differences in cesarean delivery rates between private and public maternities.