Differences in institutional cesarean delivery rates-the role of pain management.

ABSTRACT

BACKGROUND: The objective of our study was to compare cesarean delivery rates for low-risk nulliparous women in a community hospital and a tertiary-level maternity hospital and to determine factors influencing those rates. METHODS: We performed a retrospective cohort study of 857 women who did not have obstetric risk factors. The association between hospital and cesarean delivery rate was examined in a multivariate analysis using logistic regression. In a follow-up cohort study, we observed labor management for 24 couples in the community and 26 in the tertiary hospital. RESULTS: The odds of having a cesarean birth (age-adjusted) at the tertiary center were 3.4 (95% confidence interval, 2.1-5.4) compared with the community hospital. Maternal age, cervical dilatation on first examination, and use of epidural analgesia were the primary factors associated with the difference in cesarean delivery rates, with epidural analgesia having the largest effect. Labor support between the 2 hospitals appeared to be similar with the exception of increased use of ambulation in the community hospital and fewer numbers of caregivers for each woman in labor. Women in the tertiary center were more often offered epidural analgesia. CONCLUSIONS: Differences in use of epidural analgesia may contribute to differences in institutional rates of cesarean delivery. Use of epidural analgesia may be related to use of ambulation, consistency of caregiver during labor, availability of epidural, and suggestion for its use by caregivers.