Cesarean Section Rates by Type of Maternity Unit and Level of Obstetric Care: An Area-Based Study in Central Italy

Background.The rate of cesarean section in the Lazio region of Italy is one of the highest in the Western world, 26.5%. In order to evaluate the effects of nonmedical factors on cesarean section, we examined its relationship to the characteristics of maternity units in the region.Methods.We collected data from the birth certificates of 91,557 infants born to women residing in Lazio in 1988–1989 and classified all maternity units in the region by method of financing (public, semiprivate with arrangements with the national health service, and completely private) and level of obstetric care (unclassified and levels I, II, and III). The rates of cesarean section were examined for primiparous and multiparous women, taking into account birthweight, gestational age, fetal presentation, maternal age, and day of delivery.Results.The adjusted odds ratio for cesarean section (with public units of level I taken as reference) was 1.06 (primiparous) and 1.22 (multiparous) for semiprivate maternity units and 1.59 (primiparous) and 1.52 (multiparous) for private units; it increased to 1.59 (primiparous) and 1.61 (multiparous) for unclassified semiprivate units and to 2.06 (primiparous) and 1.87 (multiparous) for unclassified private units.Conclusions.The rate of cesarean section was associated in the Lazio region with private payment for hospital care and with inadequate level of obstetric care. The latter factor is of particular concern and should be investigated elsewhere.