Thesis
Analysis of caeserean section utilisation : unravelling variations, investigating the impact of policy changes, the impact and evaluating enhanced recovery pilot
- Creator
- Rights statement
- Awarding institution
- University of Strathclyde
- Date of award
- 2025
- Thesis identifier
- T17395
- Person Identifier (Local)
- 201562414
- Qualification Level
- Qualification Name
- Department, School or Faculty
- Abstract
- Caesarean section (C-section) is one of the most common surgical procedures performed in the world. The rates of the procedure have been increasing globally, while considerable variations are observed across space (areas and healthcare providers) and time. Maternal and newborn health stands as a cornerstone of a thriving society and a resilient future. The well-being of mothers and their infants is not merely a medical concern; it is a reflection of a society's commitment to compassion, equity, and the preservation of life's most precious moments. This study analyses several aspects of C-section utilization, unravelling patterns of variations, investigating the impact of a policy change and evaluating the effect of Enhanced recovery pilot after C-section. This study examines a timeframe, extending up to 2016. For that reason, the reference justifications and supporting sources are reported around that period of time (given the timeframe that these analyses were conducted and the availability of data). However, the subjects under analysis and the study remain highly relevant and importan until this present time, since C-section rates are continuously rising and variations are reported worldwide. More specifically, global C-section rates have increased to 21% (Angolile, 2023)1 - an increase that exceeds the optimal rate of 10%–15%, as this is suggested by WHO – and variations in the utilisation of the procedure are reported constantly up to this day (Shalash et al, 2022)2. In Scotland the rates of C-section have risen to nearly 35% over the last years (Scottish Government 20213; Public Health Scotland, 20214), compared to approximately 9% 1 Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. 2023 May 18;6(5):e1274. doi: 10.1002/hsr2.1274. PMID: 37216058; PMCID: PMC10196217. 2 Shalash, A., Wahdan, Y., Alsalman, H.M.M. et al. Variation of caesarean section rates in Palestinian governmental hospitals. BMC Pregnancy Childbirth 22, 943 (2022). https://doi.org/10.1186/s12884-022-05275-w 3 The Scottish Government (2021) The best start - caesarean section rates: Review report, Scottish Government. Available at: https://www.gov.scot/publications/best-start-review-caesarean-section-rates-scotland/pages/3/ (Accessed: 20 August 2023). 4 Public Health Scotland,. (2021) Births in Scotlandyear ending 31 march 2021, Births in Scottish hospitals - Year ending 31 March 2021 - Births in Scotland - Publications - Public Health Scotland. Available at: https://publichealthscotland.scot/publications/births-in-scotland/births-in-scottish-hospitals-year-ending-31-march-2021/ (Accessed: 21 August 2023). 5 in 1976 and 32% by 2017, while significant variations are reported across hospitals (Public Health Scotland, 2021). This study consists of three chapters. The first chapter explores variations in the use of Caesarean-sections in Scotland with the aim to unravel the driving forces that contribute to these patterns. Multilevel regression analysis was employed (using 2-level logistic regression models, as well as 3-level) to disentangle the variation and understand the contribution of hospital, primary and secondary healthcare professionals in the observed variation that cannot be explained by patient characteristics and clinical risk factors. The data used in this chapter were sourced from the Scottish Morbidity Records (SMR02), provided by ISD Scotland (now Public Health Scotland), covering all public hospital births between 2009 and 2016. Understanding the driving forces of variations in order to mitigate them is very important and stands as a central objective pursued by governmental bodies and policymakers in order to establish targeted strategies and achieve equity in healthcare, quality improvements, cost efficiency and evidence-based practices. The contribution of this research is significant as this is one of the few papers using multilevel analysis taking hospitals as groups of the analysis, rather than geographic regions and one of the few that employs multilevel regression modelling. The advantage of using hospitals over regions is that hospitals represent the actual decision-making units where clinical practice is implemented, offering more granular insights into provider-level variation. Moreover, it’s the first study that controls for such an extended range of possible factors that could explain the decision of having a C-section (including maternal and fetal clinical risk factors, maternal characteristic, socioeconomic factors and policy changes). Furthermore, it is the first one that examines all possible healthcare providers that could theoretically influence the decision for having a C-section (including the primary care sector) and the first one that is employing a 3-level multilevel regression to unravel healthcare variations. The second chapter aims to examine the effect of NICE guidelines, that were implemented in November 2011, on C-section rates in Scotland and explore how the availability of treatment option to women with no medical need could impact the rates of C-section. Specifically, these NICE guidelines stated that elective C-sections should be available to women upon request even in the absence of a medical indication, following appropriate counselling and support. To do so, a synthetic control method was employed, using German regions as the “donor pool” for the construction of the synthetic control unit. The results of this research could imply the association between the availability of treatment options could increase the maternity care utilization when there is no medical necessity for a specific treatment. This study contributes to the literature, as it is the first one that evaluates the health policy reform that was introduced by NICE, regarding the availability of elective C-sections to women with no medical indication for the procedure. Moreover, it is one of the few studies where synthetic control method has been applied in a UK context, examining the effect of health-related policy changes and the first one in Scotland. Finally, the third chapter evaluates the effect of the enhanced recovery pilot after C-section. The study primarily focuses on mothers who underwent elective C-section with the main goal to evaluate the effect of the pilot on maternal length of stay post operation. Twin births were excluded from the analysis to ensure comparability and avoid confounding effects. This exclusion is consistent with prior literature focusing on elective C-section utilisation. To investigate the hypothesis that mothers treated under the pilot, with shorter hospital stays post-delivery, are more prone to subsequent readmissions, we conduct a parallel analysis to determine whether those with lower average post-birth hospital stays had differing probabilities of being readmitted. While the primary emphasis of the pilot centres on mothers who underwent elective C-sections, an exploration will also be undertaken to assess the impact of the pilot on mothers who underwent emergency C-sections. To examine the above research objectives, propensity score matching (PSM) was employed along with a series of matching methods was employed, including Nearest Neighbour Matching, Inverse Probability Weighting (IPW), and Augmented IPW Regression Adjustment. Lastly, leveraging local audit data, we will compare the compliance with enhanced recovery elements to the length of hospital stay (measured in hours) following delivery. This study contributes to the literature by providing novel evidence on the impact of the Enhanced Recovery pilot in Scotland, evaluating its effect on maternal length of stay and the likelihood of hospital readmission following elective Caesarean sections. Additionally, it contributes to the literature by offering new insights into how adherence to specific elements of the pilot influences variation in postnatal length of stay.
- Advisor / supervisor
- McIntyre, Stuart
- Resource Type
- Note
- Date on thesis is 2023
- DOI
Relations
Items
| Thumbnail | Title | Date Uploaded | Visibility | Actions |
|---|---|---|---|---|
|
|
PDF of Thesis T17395 | 2025-07-23 | Public | Download |