Explaining variations in cesarean section rates: patients, facilities or policies?

Using overall rates of cesarean section and either rates of diagnosis or rates of cesarean section for the four main indications for this procedure, we analysed the variations among teaching and community hospitals in four of Ontario's six regions. The rates varied substantially in both 1979 and 1982, with the overall rate for cesarean section in 1982 being 17.1 to 21.0 per 100 deliveries in the teaching hospitals and 16.5 to 19.7 in the community hospitals. The rate of diagnosis of dystocia varied up to threefold in the teaching hospitals and up to twofold in the community hospitals. Fetal distress was diagnosed at even more variables rates. The rate of repeat cesarean section varied most in the teaching hospitals, whereas the rate of cesarean section for breech presentation varied significantly in the community and the teaching hospitals in 1982 but only in the community hospitals in 1979. Nearly all the rates increased between 1979 and 1982. Differences in patient characteristics and in availability of resources appeared less important in explaining these rate variations than differences in clinical policy.