Date Published: February 27, 2019
Publisher: Public Library of Science
Author(s): Luca Cegolon, Giuseppe Mastrangelo, Oona M. Campbell, Manuela Giangreco, Salvatore Alberico, Lorenzo Montasta, Luca Ronfani, Fabio Barbone, Ricardo Queiroz Gurgel.
Births by cesarean section (CS) usually require longer recovery time, and as a result women remain hospitalized longer following CS than vaginal delivery (VD). A number of strategies have been proposed to reduce avoidable health care costs associated with childbirth. Among these, the containment of length of hospital stay (LoS) has been identified as an important quality indicator of obstetric care and performance efficiency of maternity centres. Since improvement of obstetric care at hospital level needs quantitative evidence, we compared the maternity services of an Italian region on LoS post CS.
We conducted a population-based study in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from all its 12 maternity centres (coded from A to K) during 2005–2015. We fitted a multivariable logistic regression using LoS as a binary outcome, higher/lower than the international early discharge (ED) cutoffs for CS (4 days), controlling for hospitals as well as several factors related to the clinical conditions of the mothers and the newborn, the obstetric history and socio-demographic background. Results were expressed as adjusted odds ratios (aOR) with 95% confidence interval (95%CI). Population attributable risks (PARs) were also calculated as proportional variation of LoS>ED for each hospital in the ideal scenario of having the same performance as centre J (the reference) during calendar year 2015. Results were expressed as PAR with 95%CI. Differences in mean LoS were also investigated with a multivariable linear regression model including the same explanatory factors of the above multiple logistic regression. Results were expressed as adjusted regression coefficients (aRC) with 95%CI.
Although decreasing over the years (5.0 ± 1.7 days in 2005 vs. 4.4 ± 1.7 days in 2015), the pooled mean LoS in the whole FVG during these 11 years was still 4.7 ± 1.7 days, higher than respective international ED benchmark. The significant decreasing trend of LoS>ED over time in FVG (aOR = 0.89; 95%CI: 0.88; 0.90) was marginal as compared to the variability of LoS>ED observed among the various maternity services. Regardless it was expressed as aRC or aOR, LoS after CS was lowest in hospital C, highest in hospital D and intermediate in centres I, K, G, F, A, H, E, B and J (in descending order). The aOR of LoS being longer than ED ranged from 1.63 (95%CI:1.46; 1.81) in hospital B up to 32.09 (95%CI: 25.68; 40.10) in facility D. When hospitals were ranked by PAR the same pattern was found, even if restricting the analysis to low risk pregnancies.
Although significantly decreasing over time, the mean LoS in FVG during 2005–2015 was 4.7 days, higher than the international threshold recommended for CS. There was substantial variability in LoS by facility centre, suggesting that internal organizational processes of single hospitals should be improved by enforcing standardized guidelines and using audits, economic incentives and penalties if need be.
Cesarean sections (CS) are among the most common and long-standing obstetric surgical procedures worldwide, employed when vaginal deliveries (VD) are impossible or in case of life threatening risks for the mother and/or the newborn [1–4]. Although, CS are pushed also by a number of other factors including maternal request, fear of medico-legal backlashes, economic convenience and social/cultural trends [5–9]. Nonetheless, CSs entail health risks for the mother and the newborn, such as surgical site infections, venous thrombo-embolism, shock, hemorrhage, early childhood anemia. Moreoveor, births by CS usually require longer time to recovery [9–11], and as a result, women remain hospitalized longer following CS than VD, with subsequent considerable enhancement of health care costs [12–14].
The methods have been reported in a previous paper  and are herewith briefly described.
Fig 1 shows the flowchart displaying the various selection criteria applied to the initial eligible births (N = 109,246) to obtain the final number of CSs available for the analysis. In the entire FVG the total number of CSs was 26,467 during 2005–2015.
The mean LoS post CS in FVG during 2005–2015 FVG was 4.7 days, hence higher than the international threshold recommended post CS. Although there was a significantly decreasing trend in the average LoS and proportion of LoS>ED over the years in the whole region, considerable variability was observed by maternity centre. FVG hospitals have the power to improve internal organizational processes to shorten LoS and accelerate the bed turnover whilst guaranteeing quality of care. Policy makers could effectively improve the management and clinical governance of maternity services by enforcing standardized guidelines, using audits, economic incentives and penalties if need be. For any case of LoS>ED following CS medical records should be scrutinized to justify prolonged LoS. However, integration of inpatient and outpatient services is a critical step to ensure that the mother and the newborn receive appropriate follow-up care in the community . Moreover, re-admission rates should be investigated in relation to the eventual introduction of ED policies post CS, using a systematic approach, also employing patients’ satisfaction surveys.