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A global reference for caesarean section rates (C-Model) : a multicountry cross-sectional study

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Abstract
Objective: To generate a global reference for caesarean section (CS) rates at health facilities. Design: Cross-sectional study. Setting: Health facilities from 43 countries. Population/Sample: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10045875 women giving birth from 43 countries for model testing. Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (). Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.
Keywords
METAANALYSIS, DELIVERY, Benchmarking, caesarean delivery rates, caesarean section rates, logistic regression

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Chicago
Souza, JP, AP Betran, A Dumont, B de Mucio, CM Gibbs Pickens, C Deneux-Tharaux, E Ortiz-Panozo, et al. 2016. “A Global Reference for Caesarean Section Rates (C-Model) : a Multicountry Cross-sectional Study.” Bjog-an International Journal of Obstetrics and Gynaecology 123 (3): 427–436.
APA
Souza, J., Betran, A., Dumont, A., de Mucio, B., Gibbs Pickens, C., Deneux-Tharaux, C., Ortiz-Panozo, E., et al. (2016). A global reference for caesarean section rates (C-Model) : a multicountry cross-sectional study. BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, 123(3), 427–436.
Vancouver
1.
Souza J, Betran A, Dumont A, de Mucio B, Gibbs Pickens C, Deneux-Tharaux C, et al. A global reference for caesarean section rates (C-Model) : a multicountry cross-sectional study. BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY. 2016;123(3):427–36.
MLA
Souza, JP et al. “A Global Reference for Caesarean Section Rates (C-Model) : a Multicountry Cross-sectional Study.” BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY 123.3 (2016): 427–436. Print.
@article{8512023,
  abstract     = {Objective: To generate a global reference for caesarean section (CS) rates at health facilities. 
Design: Cross-sectional study. 
Setting: Health facilities from 43 countries. 
Population/Sample: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10045875 women giving birth from 43 countries for model testing. 
Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. 
Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. 
Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (). 
Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. },
  author       = {Souza, JP and Betran, AP and Dumont, A and de Mucio, B and Gibbs Pickens, CM and Deneux-Tharaux, C and Ortiz-Panozo, E and Sullivan, E and Ota, E and Togoobaatar, G and Carroli, G and Knight, H and Zhang, J and Cecatti, JG and Vogel, JP and Jayaratne, K and Leal, MC and Gissler, M and Morisaki, N and Lack, N and Oladapo, OT and Tuncalp, O and Lumbiganon, P and Mori, R and Quintana, S and Costa Passos, AD and Marcolin, AC and Zongo, A and Blondel, B and Hernandez, B and Hogue, CJ and Prunet, C and Landman, C and Ochir, C and Cuesta, C and Pileggi-Castro, C and Walker, D and Alves, D and Abalos, E and Moises, ECD and Vieira, EM and Duarte, G and Perdona, G and Gurol-Urganci, I and Takahiko, K and Moscovici, L and Campodonico, L and Oliveira-Ciabati, L and Laopaiboon, M and Danansuriya, M and Nakamura-Pereira, M and Costa, ML and Torloni, MR and Kramer, MR and Borges, P and Olkhanud, PB and Perez-Cuevas, R and Agampodi, SB and Mittal, S and Serruya, S and Bataglia, V and Li, Z and Temmerman, Marleen and Guelmezoglu, AM},
  issn         = {1470-0328},
  journal      = {BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY},
  keywords     = {METAANALYSIS,DELIVERY,Benchmarking,caesarean delivery rates,caesarean section rates,logistic regression},
  language     = {eng},
  number       = {3},
  pages        = {427--436},
  title        = {A global reference for caesarean section rates (C-Model) : a multicountry cross-sectional study},
  url          = {http://dx.doi.org/10.1111/1471-0528.13509},
  volume       = {123},
  year         = {2016},
}

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