Can Cesarean Section Rate Be Used as a Hospital-Wide Quality Indicator in Korean Hospitals?

Park, Joong Shin; Kang, Chul Hwan; Kim, Chang Yup

Abstract

With the sharply increasing practice of cesarean section(C/S), formerly known as a landmark of developing medical technology, appropriateness of the procedure has been widely inquired into. Appropriateness of a specific procedure could be an indicator for quality, at the individual or organizational level. Cesarean section rate is regarded as a sensitive indicator reflecting clinical quality at the hospital level. We are interested in the validity and significance of C/S rate as a quality indicator in Korean hospitals, in addition to the current status of the practice. This study was carried out retrospectively based on the clinical records of cesarean sections in 32 hospitals nationwide from March to May 1996. Standardized survey format was distributed, and reviews were performed by volunteer surveyors from each hospital after two sessions of pre-survey education. The results were as follows : 1. There were 13,241 deliveries with 4,599 cases of cesarean sections, giving an incidence of 38.5%. This result shows the incidence of cesarean section was 1.6 times higher than U.S. and about four times higher than European countries. 2. The monthly incidence of cesarean section was not variable, but it shows great differences among the hospitals. 3. The incidences of cesarean sections were variable among different age groups with marked higher rate in older one. 4. Most of deliveries were with gestational period from 37 to 44 weeks(91%), in which C/S rate was 39%. For pregnancies with less than or equal to 32 weeks, the rate was 21% and for more than or equal to 45 weeks the rate was 25%. 5. The most frequent indication of cesarean birth was previous cesarean section(37.7%), followed by cephalopelvic disproportion and dystocia(24.4%). 6. There were no statistical differences in cesarean section rates by hospital variables such as ownership, teaching status, proportion of specialists, number of physicians per bed, number of nurses per bed, regional location, and number of beds. Exceptionally, hospitals with independent obstetrics department, separated from gynecology, showed significant lower rate than hospitals with conventional obstetrics-gynecology department. We could confirm higher C/S rate than any other countries. However, C/S rate, not significantly different among hospitals with variable quality level in structural aspect, was not acceptable as a sensitive indicator for clinical quality at the hospital level. Different rates between comparable organizational settings, sometimes indirectly related to the clinical quality, suggested that more studies focused on other aspects of quality than structure should be needed.