title: Cesarean delivery rates and obstetric culture - an Italian register-based study.
abstract: BACKGROUND
  Cesarean delivery rates are rising due to multiple factors, including less use of operative vaginal delivery and vaginal birth after cesarean delivery, which often reflect local obstetric practices. Objectives of the study were to analyze the relations between cesarean delivery, these practices, and perinatal outcomes.
  
  
  METHODS
  We included all deliveries in the 72 hospitals of Lombardia, a region in northern Italy, during the year 2013. The delivery certificate was used as data source. Pearson's correlation coefficient and logistic regression were used for statistical analysis.
  
  
  RESULTS
  We included 87 896 deliveries. The number of deliveries per hospital ranged from 140 to 6123. The rate of cesarean delivery was 28.3% (range 9.9-86.4%), operative vaginal delivery 4.7% (range 0.2-10.0%), and vaginal birth after cesarean 17.3% (range 0-79.2%). We found a significant inverse correlation between rates of overall cesarean delivery and operative vaginal delivery (r = -0.25, p = 0.04). The correlation between rate of overall cesarean delivery and vaginal birth after cesarean was also inverse and significant (r = -0.57, p < 0.001). There was no association between overall cesarean delivery rate and the rates of Apgar score at 5 min <7 in term and late preterm neonates (r = -0.92, p = 0.46) and of perinatal mortality (r = -0.19, p = 0.13), respectively. The associations were independent of hospital volume of activity.
  
  
  CONCLUSIONS
  An obstetric practice that encourages vaginal instrumental delivery in delayed second stage of labor or vaginal birth after previous cesarean delivery, could reduce the rising cesarean delivery rate. This will require a change in obstetric culture, continuing education of healthcare providers, and leadership.
authors.affiliation: Department of Obstetrics and Gynecology, ASST Vimercate, Carate Brianza Hospital, University of Milano-Bicocca, Milan, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Plevani
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione MBBM, ASST Monza, University of Milano-Bicocca, Milan, Italy.
authors.forename: Maddalena
authors.initials: M
authors.lastname: Incerti
authors.affiliation: Department of Informatics, ASST Vimercate, Vimercate Hospital, Vimercate, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Del Sorbo
authors.affiliation: Department of Obstetrics and Gynecology, ASST Vimercate, Carate Brianza Hospital, University of Milano-Bicocca, Milan, Italy.
authors.forename: Armando
authors.initials: A
authors.lastname: Pintucci
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione MBBM, ASST Monza, University of Milano-Bicocca, Milan, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Vergani
authors.affiliation: General Management for Health, Lombardy Region, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Merlino
authors.affiliation: Department of Obstetrics and Gynecology, ASST Vimercate, Carate Brianza Hospital, University of Milano-Bicocca, Milan, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Locatelli
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000523:psychology / Q000706:statistics & numerical data*; D003466:Cultural Characteristics; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007558:Italy / Q000453:epidemiology; D009774:Obstetrics; D010818:Practice Patterns, Physicians'; D011247:Pregnancy; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies
keywords: Cesarean; delivery; education; prenatal care; uterine scar