title: Rising cesarean deliveries among apparently low-risk mothers at university teaching hospitals in Jordan: analysis of population survey data, 2002-2012.
abstract: BACKGROUND
  Cesarean delivery conducted without medical indication places mothers and infants at risk for adverse outcomes. This study assessed changes in trends of, and factors associated with, cesarean deliveries in Jordan, from 2002 to 2012.
  
  
  METHODS
  Data for ever-married women ages 15-49 years from the 2002, 2007, and 2012 Jordan Population and Family Health Surveys were used. Analyses were restricted to mothers who responded to a question regarding the hospital-based mode of delivery for their last birth occurring within the 5 years preceding each survey (2002, N = 3,450; 2007, N = 6,307; 2012, N = 6,365). Normal birth weight infants and singleton births were used as markers for births that were potentially low risk for cesarean delivery, because low/high birth weight and multiple births are among the main obstetric variables that have been documented to increase risk of cesareans. Weighted descriptive and multivariate analyses were conducted using 4 logistic regression models: (1) among all mothers; and among mothers stratified (2) by place of delivery; (3) by birth weight of infants; and (4) by singleton vs. multiple births.
  
  
  RESULTS
  The cesarean delivery rate increased significantly over time, from 18.2% in 2002, to 20.1% in 2007, to 30.3% in 2012. Place of delivery, birth weight, and birth multiplicity were significantly associated with cesarean delivery after adjusting for confounding factors. Between 2002 and 2012, the rate increased by 99% in public hospitals vs. 70% in private hospitals; by 93% among normal birth weight infants vs. 73% among low/high birth weight infants; and by 92% among singleton births vs. 29% among multiple births. The changes were significant across all categories except among multiple births. Further stratification revealed that the cesarean delivery rate was 2.29 times higher in university teaching hospitals (UTHs) than in private hospitals (P< .001), and 2.31 times higher than in government hospitals (P< .001). Moreover, in UTHs, the rate was higher among normal birth weight infants (adjusted OR = 2.15) and singleton births (adjusted OR = 2.39).
  
  
  CONCLUSIONS
  The rising cesarean delivery rate among births that may have been at low risk for cesarean delivery, particularly in UTHs, indicates that many cesarean deliveries may increasingly be performed without any medical indication. More vigilant monitoring of data from routine health information systems is needed to reduce unnecessary cesarean deliveries in apparently low-risk groups.
authors.affiliation: Graduate School of Tokyo Medical and Dental University, Division of Public Health, Department of International Health and Medicine , Tokyo , Japan.
authors.forename: Rami
authors.initials: R
authors.lastname: Al Rifai
mesh_terms: D000293:Adolescent; D000328:Adult; D001724:Birth Weight; D002585:Cesarean Section / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D019538:Health Care Surveys; D006785:Hospitals, University; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007597:Jordan; D016015:Logistic Models; D008875:Middle Aged; D009099:Multiple Birth Offspring / Q000706:statistics & numerical data; D016017:Odds Ratio; D011247:Pregnancy; D012016:Reference Values; D012306:Risk; D014495:Universities; D055815:Young Adult