With rising rates of cesarean sections (CSs) in Canada and worldwide, nonclinical factors for CS warrant consideration.
Objective:
To determine the association between a primigravid woman's neighborhood income and rates of CSs.
Materials and Methods:
A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CSs were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was the neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on the CS rate.
Results:
The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CSs (relative risk, RR 1.06, 95% confidence interval, CI [1.02–1.11]). Following adjustment for important confounders, there was no longer an association between the neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99–1.01]). Women in the highest quintile were more likely to have greater maternal age (p < 0.01).
Conclusions:
Although differences in CS rates are seen by the neighborhood income quintile, they appear to be mediated through a combination of maternal age and other clinical factors. Neighborhood income does not appear to be an independent predictor of CS.
Get full access to this article
View all access options for this article.
References
1.
Canadian Institue for Health Information [CIHI]. Inpatient Hospitalizations, Surgeries, Newborns and Childbirth Indicators, Inpatient Hospitalization Volumes and Lengths of Stay Declining. Ottawa, Canada: CIHI, 2015:1–3.
2.
LeebK, BaibergenovaA, WenE, WebsterG, ZelmerJ. Are there socio-economic differences in caesarean section rates in Canada?. Healthc Policy, 2005; 1:48–54.
BergholtT, StenderupJK, Vedsted-JakobsenA, HelmP, LenstrupC. Intraoperative surgical complication during cesarean section: An observational study of the incidence and risk factors. Acta Obstet Gynecol Scand, 2003; 82:251–256.
XieR-H, GaudetL, KrewskiD, GrahamID, WalkerMC, WenSW. Higher cesarean delivery rates are associated with higher infant mortality rates in industrialized countries. Birth, 2015; 42:62–69.
7.
Canadian Institue for Health Information [CIHI]. Inpatient Hospitalizations, Surgeries, Newborns and Childbirth Indicators, 2016–2017 Inpatient Hospitalization Rate Declining Over Time. Ottawa, Canada: CIHI, 2018.
8.
World Health Organization Human Reproduction Programme, 10April2015. WHO statement on caesarean section rates. Reprod Health Matters, 2015; 23:149–150.
9.
Canadian Institue for Health Information [CIHI]. C-Section Rates Continue to Increase While Birth Rates Decline. Ottawa, Canada: CIHI, 2018.
10.
ChenI, OpiyoN, TavenderE, et al.Non-clinical interventions for reducing unnecessary caesarean section (Review). Cochrane Database Syst Rev, 2018; 9:CD005528.
11.
DunnJR, DyckI. Social determinants of health in Canada's immigrant population: Results from the National Population Health Survey. Soc Sci Med, 2000; 51:1573–1593.
12.
Canadian Institue for Health Information [CIHI]. Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada. Canadian Institute for Health Information—Rport. Ottawa, Canada: CIHI, 2008.
13.
MikkonenJ, RaphaelD. Social Determinants of Health: The Canadian Facts. Toronto, ON: York University School of Health Policy and Management, 2010.
14.
Technical Report and Factors Influencing Health. Trends in Income-Related Health Inequalities in Canada. 1998–2011, 2015:1692.
15.
UrquiaML, FrankJW, GlazierRH. Moineddin R. Birth outcomes by neighbourhood income and recent immigration in Toronto. Health Rep, 2007; 18:21–30.
16.
GagnonAJ, MerryL, HaaseK. Predictors of emergency cesarean delivery among international migrant women in Canada. Int J Gynecol Obstet, 2013; 121:270–274.
17.
MumtazZ, O'BrienB, HigginbottomG. Navigating maternity health care: A survey of the Canadian prairie newcomer experience. BMC Pregnancy Childbirth, 2014; 14:4.
18.
Public Health Agency of Canada. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa, Canada: PHAC, 2009.
19.
Canadian Institue for Health Information [CIHI]. CIHI Data Quality Study of the 2007–2008 Discharge Abstract Database. Ottawa, Canada: CIHI, 2010:1–86.
20.
Canadian Institue for Health Information [CIHI]. CIHI Data Quality Study of the 2009–2010 Discharge Abstract Database. Ottawa, Canada: CIHI, 2012:1–139.
21.
Canadian Institue for Health Information [CIHI]. Data Quality Study of the 2015–2016 Discharge Abstract Database: A Focus on Hospital Harm. Ottawa, Canada: CIHI, 2016.
22.
BrennanSL, LeslieWD, LixLM. Is lower income associated with an increased likelihood of qualification for treatment for osteoporosis in Canadian women?. Osteoporos Int, 2014; 25:273–279.
23.
ChenI, LisonkovaS, AllaireC, WilliamsC, YongP, JosephKS. Routes of hysterectomy in women with benign uterine disease in the Vancouver Coastal Health and Providence Health Care regions: A retrospective cohort analysis. CMAJ Open, 2014; 2:E273–E280.
24.
LisonkovaS, HaslamMD, DahlgrenL, ChenI, SynnesAR, LimKI. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ, 2016; 188:E456–E465.
25.
ChenI, WiseMR, DunnS, et al.Social and geographic determinants of hysterectomy in Ontario: A population-based retrospective cross-sectional analysis. J Obstet Gynaecol Can, 2017; 39:861–869.
26.
ChungSH, SeolHJ, ChoiYS, OhSY, KimA, BaeCW. Changes in the cesarean section rate in Korea (1982–2012) and a review of the associated factors. J Korean Med Sci, 2014; 29:1341–1352.
27.
JanoudiG, KellyS, YasseenA, HamamH, MorettiF, WalkerM. Factors associated with increased rates of caesarean section in women of advanced maternal age. J Obstet Gynaecol Can, 2015; 37:517–526.
28.
BayrampourH, HeamanM. Advanced maternal age and the risk of cesarean birth: A systematic review. Birth, 2010; 37:219–226.
29.
RosenthalAN, Paterson-BrownS. Is there an incremental rise in the risk of obstetric intervention with increasing maternal age?. Br J Obstet Gynaecol, 1998; 105:1064–1069.
30.
WeaverJ, Magill-CuerdenJ. ‘Too posh to push’: The rise and rise of a catchphrase. Birth, 2013; 40:264–271.
31.
JollyM, SebireN, HarrisJ, RobinsonS, ReganL. The risks associated with pregnancy in women aged 35 years or older. Hum Reprod, 2000; 15:2433–2437.
32.
YuanW, SteffensenFH, NielsenGL, MøllerM, OlsenJ, SørensenHT. A population-based cohort study of birth and neonatal outcome in older primipara. Int J Gynecol Obstet, 2000; 68:113–118.
33.
City of Ottawa. Part A: Operating Expenditures. 2018.
34.
CBC News. The Big 7: 2016 Federal Budget Items That Matter to Ottawa. 2016.
35.
StaffordRS. Alternative strategies for controlling rising cesarean section rates. JAMA, 1990; 263:683–687.
36.
GibbonsL, BelizánJM, LauerJA, BetránAP, MerialdiM, AlthabeF. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Rep Backgr Pap, 2010; 1–31. DOI: 10.1017/CBO9781107415324.004.
37.
GibbonsL, BelizanJM, LauerJA, BetranAP, MerialdiM, AlthabeF. Inequities in the use of cesarean section deliveries in the world. Am J Obstet Gynecol, 2012; 206:331.e1–e19.
38.
MerryL, SmallR, BlondelB, GagnonAJ. International migration and caesarean birth: A systematic review and meta-analysis. BMC Pregnancy Childbirth, 2013; 13:27.
39.
DonnaS. Promoting Normal Birth: Research, Reflections and Guidelines. United Kingdom: Fresh Heart Publishing, 2011.
40.
RäisänenS, GisslerM, KramerMR, HeinonenS. Influence of delivery characteristics and socioeconomic status on giving birth by caesarean section—A cross sectional study during 2000–2010 in Finland. BMC Pregnancy Childbirth, 2014; 14:120.
41.
LindquistA, KurinczukJJ, RedshawM, KnightM. Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: Findings from the 2010 National Maternity Survey. Br J Obstet Gynaecol, 2015; 122:1610–1617.
42.
Health Canada. Canada Health Act—Annual Report 2016–17. 2018.
43.
CaanW. The spirit level. Why equality is better for everyone. J Pub Ment Health, 2011; 10:250.
44.
PickettKE, WilkinsonRG. Income inequality and health: A causal review. Soc Sci Med, 2015; 128:316–326.
45.
LynchJW, KaplanGA. Understanding how inequality in the distribution of income affects health. J Health Psychol, 1997; 2:297–314.
46.
MustardCA, DerksenS, BerthelotJM, WolfsonM. Assessing ecologic proxies for household income: A comparison of household and neighbourhood level income measures in the study of population health status. Health Place, 1999; 5:157–171.
47.
GrootW, van den BrinkHM. What does education do to our health?. Proc Copenhagen Symp, 2006; 4:355–363.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
