Institutional factors in cesarean delivery rates: policy and research implications.

OBJECTIVE: To examine the association of health care institutional characteristics with cesarean delivery.
METHODS: Cross-sectional data from Taiwan's National Health Insurance database was used, covering all 270774 women admitted for singleton deliveries, in 2000. Bivariate and multiple logistic regression analyses were used.
RESULTS: The overall cesarean rate was 32.3% of all deliveries. Obstetrics and gynecology clinics (with fewer than 10 beds) had a very high likelihood of cesarean delivery compared with all categories of hospitals (odds ratios 17-25), after adjusting for clinical complications and patient, physician, and institutional characteristics. The likelihood of cesarean delivery was similar across hospitals, regardless of level and ownership category. High cesarean propensity at clinics arose from higher cesarean rates in all complication categories, including "No complications." The overall hospital cesarean rate, 31.2%, is also higher than that in other developed countries with universal health care coverage.
CONCLUSION: Taiwan has very high cesarean rates, with a particularly high propensity for this procedure at clinics. The cesarean delivery profile in the various clinical complication categories suggests a significantly lower clinical threshold triggering cesarean delivery decisions in Taiwan, especially at obstetrics and gynecology clinics. Countries currently having or contemplating large expansions in health insurance coverage should document obstetric practice profiles before initiating coverage expansions. There is also a need for well designed research on the medical and life-satisfaction impacts of cesarean compared with vaginal delivery to enable an informed policy stand on this issue.