Rising cesarean deliveries among apparently low-risk mothers at university teaching hospitals in Jordan: analysis of population survey data, 2002–2012

Rami Al Rifai

doi:10.9745/GHSP-D-14-00027

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FIGURE.
Selection (Unweighted Numbers)

Abbreviation: JPFHS, Jordan Population and Family Health Survey.

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TABLE 1. Background Characteristics of Survey Respondents by Year of Survey, Weighted Numbers (Percentages)

Characteristics	2002 (N = 3,450)	2007 (N = 6,307)	2012 (N = 6,365)
SOCIODEMOGRAPHIC
Age, y
15–19	55 (1.6)	123 (1.9)	135 (2.1)
20–24	515 (14.9)	974 (15.4)	854 (13.4)
25–29	884 (25.6)	1654 (26.2)	1669 (26.2)
≥ 30	1997 (57.9)	3556 (56.4)	3707 (58.2)
Place of Residence
Urban	2705 (78.4)	5298 (84.0)	5198 (81.7)
Rural	746 (21.6)	1009 (16.0)	1167 (18.3)
Geographic Region
Central	2191 (63.5)	3908 (62.0)	3935 (61.8)
North	930 (27.0)	1844 (29.2)	1821 (28.6)
South	329 (9.5)	555 (8.8)	609 (9.6)
Mother's Education
No education	128 (3.7)	147 (2.3)	114 (1.8)
Primary	277 (8.0)	337 (5.3)	373 (5.9)
Secondary	2087 (60.5)	3885 (61.6)	3825 (60.1)
Higher	959 (27.8)	1939 (30.7)	2053 (32.2)
Husband's Education
No education	65 (1.9)	91 (1.5)	59 (0.9)
Primary	371 (10.8)	665 (10.6)	661 (10.4)
Secondary	1980 (57.4)	3793 (60.3)	4000 (62.8)
Higher	1034 (30.0)	1745 (27.7)	1645 (25.8)
Missing (Do not know)		12 (0.2)	1 (0.02)
Employment
Unemployed	3101 (89.9)	5526 (87.6)	5381 (84.5)
Employed	350 (10.1)	781 (12.4)	985 (15.5)
Place of Delivery
Public sector	2229 (64.6)	4036 (64.0)	4230 (66.5)
Private sector	1221 (35.4)	2271 (36.0)	2135 (33.5)
Wealth Index
Poorest	786 (22.8)	1462 (23.2)	1313 (20.6)
Poorer	881 (25.5)	1475 (23.4)	1365 (21.4)
Middle	740 (21.4)	1368 (21.7)	1437 (22.6)
Richer	594 (17.2)	1131 (17.9)	1291 (20.3)
Richest	450 (13.0)	872 (13.8)	960 (15.1)
OBSTETRIC
Age at First Birth, y
12–18	687 (19.9)	1110 (17.6)	917 (14.4)
19–24	2010 (58.3)	3661 (58.1)	3747 (58.9)
25–30	645 (18.7)	1289 (20.4)	1369 (21.5)
> 30	107 (3.1)	246 (3.9)	332 (5.2)
Parity in Last 5 Years
1	1881 (54.5)	3531 (56.0)	3733 (58.6)
2	1263 (36.6)	2254 (35.7)	2182 (34.3)
≥ 3	307 (8.9)	522 (8.3)	451 (7.1)
Birth Weight, g
Normal (2500–3999)	2618 (75.9)	4916 (77.9)	4907 (77.1)
Low or High (< 2500 or ≥ 4000)	832 (24.1)	1391 (22.1)	1458 (22.9)
Birth Multiplicity
Singleton birth	3371 (97.7)	6185 (98.1)	6225 (97.8)
Multiple birth	80 (2.3)	123 (1.9)	140 (2.2)

All data are reported as No. (%).

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TABLE 2. Cesarean Delivery Rate by Year of Survey and Background Characteristics, Weighted Percentages

Characteristics	2002		2007		2012
Characteristics	%	P Value	%	P Value	%	P Value	Percentage Point Difference^a	P Value for Trend^b
*Overall Rate*	*18.2*		*20.1*		*30.3*
Age, y		.001		<.001		<.001		.53
15–19	14.5		20.3		22.2		7.7
20–24	14.6		11.1		25.2		10.6
25–29	15.5		16.9		28.0		12.5
≥ 30	20.5		24.0		32.8		12.3
Place of Residence		.33		.45		.12		.74
Urban	18.6		20.3		30.7		12.1
Rural	17.0		19.2		28.4		11.4
Geographic Region		.008		.18		.06		.37
Central	19.7		20.2		31.2		11.5
North	15.1		19.1		28.2		13.1
South	17.3		22.7		30.9		13.6
Mother's Education		.01		.001		<.001		.75
No education	22.0		24.5		23.5		1.5
Primary	23.1		24.9		40.2		17.1
Secondary	16.6		18.6		29.0		12.4
Higher	19.9		22.0		31.3		11.4
Partner's Education		.13		.44		<.001		.48
No education	23.1		20.7		28.8		5.7
Primary	16.9		21.5		33.0		16.1
Secondary	17.3		19.4		28.1		10.8
Higher	20.3		20.9		34.6		14.3
Employment		.02		<.001		<.001		.02
Unemployed	17.7		19.4		28.5		10.8
Employed	22.6		24.8		40.1		17.5
Place of Delivery		.004		.005		.02		.53
Public sector	16.8		19.0		29.4		12.6
Private sector	20.8		22.0		32.2		11.4
Wealth Index		.18		<.001		<.001		.47
Poorest	17.4		17.0		28.8		11.4
Poorer	16.3		17.1		25.4		9.1
Middle	18.1		19.2		33.3		15.2
Richer	20.0		24.0		31.0		11.0
Richest	21.1		26.5		34.0		12.9
Parity in Last 5 Years		<.001		.02		.01		.01
1	20.1		21.3		30.0		9.9
2	14.8		18.5		29.5		14.7
≥ 3	20.6		18.4		36.6		16.0
Age at First Birth, y		<.001		<.001		<.001		<.001
12–18	16.9		16.8		24.3		7.4
19–24	16.7		17.0		27.0		10.3
25–30	20.3		28.2		34.5		14.2
> 30	43.9		38.5		66.9		23.0
Birth Weight, g		<.001		<.001		<.001		.85
Normal (2500–3999)	16.3		18.1		28.4		12.1
Low/High (< 2500 or ≥ 4000)	24.2		27.1		36.6		12.4
Birth Multiplicity		<.001		<.001		<.001		<.001
Singleton birth	17.3		19.3		29.5		12.2
Multiple birth	60.0		59.3		65.7		5.7

↵a Percentage point difference between 2002 and 2012.
↵b P value for the trend was obtained from logistic regression models by using outcome and explanatory variables as continuous variables and including interaction terms between survey year and each tested explanatory variable for the years 2002 and 2012.

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TABLE 3. Bivariate and Multivariate Logistic Regression Analysis on Trends in the Cesarean Delivery Rate, Among All Mothers and Stratified by Place of Delivery, Birth Weight, and Birth Multiplicity According to Year of Survey

	No. (%)	OR (95% CI)	aOR (95% CI)
Among All Mothers
2002	629 (18.2)	1.00	1.00
2007	1267 (20.1)	1.13 (1.01–1.25)^*	1.13 (1.01–1.26)^*
2012	1929 (30.3)	1.95 (1.76–2.16)^***	1.90 (1.71–2.11)^***
By Place of Delivery
Public Sector
2002	375 (16.8)	1.00	1.00
2007	768 (19.0)	1.16 (1.01–1.33)^*	1.15 (1.00–1.33)^*
2012	1242 (29.4)	2.05 (1.80–2.34)^***	1.99 (1.74–2.28)^***
Private Sector
2002	254 (20.8)	1.00	1.00
2007	499 (22.0)	1.07 (0.90–1.27)	1.06 (0.88–1.26)
2012	687 (32.2)	1.80 (1.53–2.12)^***	1.70 (1.43–2.02)^***
By Birth Weight
Normal
2002	428 (16.3)	1.00	1.00
2007	890 (18.1)	1.13 (0.99–1.28)	1.11 (0.98–1.26)
2012	1395 (28.4)	2.03 (1.80–2.29)^***	1.93 (1.71–2.19)^***
Low/High
2002	201 (24.2)	1.00	1.00
2007	377 (27.1)	1.17 (0.96–1.42)	1.13 (0.93–1.39)
2012	534 (36.6)	1.81 (1.50–2.20)^***	1.73 (1.42–2.10)^***
By Birth Multiplicity
Singleton Birth
2002	582 (17.3)	1.00	1.00
2007	1194 (19.3)	1.15 (1.03–1.28)^*	1.14 (1.02–1.27)^*
2012	1838 (29.5)	2.01 (1.81–2.23)^***	1.92 (1.72–2.13)^***
Multiple Birth
2002	48 (60.0)	1.00	1.00
2007	73 (589.3)	0.99 (0.55–1.75)	0.98 (0.49–1.95)
2012	92 (65.7)	1.28 (0.72–2.26)	1.29 (0.64–2.58)

Abbreviations: aOR, adjusted odds ratio (for all covariates under analysis); CI, confidence interval; OR, odds ratio.
P value for the trend was obtained by entering the survey year as a continuous variable.
↵^*P< .05; ^*** P< .001.

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TABLE 4. Multivariate Logistic Regression Analysis on Trends in the Cesarean Delivery Rate by Place of Delivery, Stratified by Birth Weight and Birth Multiplicity According to Year of Survey

	Public Hospitals (N = 10,496)		Private Hospitals (N = 5,627)
	No. (%)	aOR (95% CI)	No. (%)	aOR (95% CI)
By Birth Weight
Normal
2002	247 (14.8)	1.00	181 (19.1)	1.00
2007	525 (17.0)	1.17 (0.99–1.39)	365 (19.9)	1.00 (0.82–1.23)
2012	877 (27.4)	2.06 (1.76–2.42)^***	519 (30.4)	1.71 (1.41–2.09)^***
Low/High
2002	128 (22.9)	1.00	73 (26.7)	1.00
2007	242 (25.3)	1.12 (0.87–1.45)	135 (31.0)	1.22 (0.85–1.75)
2012	366 (35.6)	1.87 (1.46–2.38)^***	168 (39.1)	1.66 (1.16–2.38)^**
By Birth Multiplicity
Singleton Birth
2002	347 (16.0)	1.00	234 (19.6)	1.00
2007	718 (18.2)	1.15 (0.99–1.33)	476 (21.3)	1.08 (0.90–1.29)
2012	1171 (28.3)	2.00 (1.74–2.29)^***	667 (31.8)	1.76 (1.47–2.09)^***
Multiple Birth
2002	28 (50.9)	1.00	20 (80.0)	1.00
2007	49 (60.5)	1.85 (0.78–4.35)	23 (56.1)	0.32 (0.05–2.09)
2012	72 (72.0)	3.05 (1.27–7.33)^*	20 (50.0)	0.08 (0.01–0.78)^*

Abbreviations: aOR, adjusted odds ratio (for all covariates under analysis); CI, confidence interval.
P value for the trend was obtained by entering the survey year as a continuous variable.
↵^*P< .05; ^** P< .01; ^*** P< .001.

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TABLE 5. Multivariate Logistic Regression Analysis on Cesarean Delivery Rate Among Mothers Delivering in Public Hospitals by Year of Survey, Stratified by Birth Weight and Birth Multiplicity According to Type of Public Hospital

	2002		2007		2012		All Years Combined
	%	aOR (95% CI)	%	aOR (95% CI)	%	aOR (95% CI)	%	aOR (95% CI)
All Mothers
Private	20.8	1.00	22.0	1.00	32.2	1.00	25.6	1.00
Government (public)^a	16.6	0.86 (0.69–1.07)	18.1	0.87 (0.75–1.02)	28.5	0.91 (0.79–1.04)	21.9	0.90 (0.83–0.99)^*
UTH (public)	26.7	1.08 (0.57–2.05)	50.0	4.24 (2.85–6.29)^***	49.1	1.69 (1.21–2.33)^**	45.6	2.29 (1.82–2.88)^***
Mothers Delivering in Public Hospitals (N = 10,494)
Government	16.6	1.00	18.1	1.00	28.5	1.00	21.9	1.00
UTH	26.7	1.19 (0.63–2.27)	50.0	4.20 (2.80–6.28)^***	49.1	1.69 (1.21–2.37)^**	45.6	2.31 (1.83–2.92)^***
Mothers Delivering in Public Hospitals By Birth Weight
Normal Birth Weight
Government	14.5	1.00	16.2	1.00	26.5	1.00	19.9	1.00
UTH	23.9	1.18 (0.55–2.55)	44.1	3.44 (2.22–5.33)^***	47.1	1.55 (1.06–2.27)^*	42.2	2.15 (1.65–2.80)^***
Low/High Birth Weight
Government	22.5	1.00	24.2	1.00	34.7	1.00	28.1	1.00
UTH	35.7	1.24 (0.35–4.41)	83.3	27.50 (6.54–115.5)^***	57.1	2.30 (1.08–4.88)^*	60.6	3.13 (1.82–5.37)^***
Mothers Delivering in Public Hospitals By Birth Multiplicity
Singleton Birth
Government	15.7	1.00	17.2	1.00	27.6	1.00	21.0	1.00
UTH	29.6	1.73 (0.91–3.29)	48.7	4.06 (2.70–6.08)^***	46.7	1.62 (1.15–2.28)^**	44.7	2.39 (1.88–3.02)^***
Multiple Birth
Government	57.1	1.00	59.5	1.00	69.2	1.00	63.0	1.00
UTH	0.0	NA	100.0	NA	100.0	NA	64.7	1.02 (0.31–3.38)

Abbreviations: aOR, adjusted odds ratio (for all covariates under analysis); CI, confidence interval; NA, not applicable; UTH, university teaching hospital.
↵a Government hospitals include hospitals run by the Ministry of Health or the Royal Medical Services.
↵^*P< .05; ^** P< .01; ^*** P< .001.

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TABLE 6. Logistic Regression Analysis on Cesarean Delivery Rate by Background Characteristics, Among All Mothers From All Survey Datasets (2002–2012)

	OR (95% CI)	aOR (95% CI)
Age, y
15–19	1.00	1.00
20–24	0.85 (0.63–1.14)	0.82 (0.60–1.12)
25–29	1.01 (0.80–1.42)	0.97 (0.72–1.31)
≥ 30	1.47 (1.11–1.94)^**	1.05 (0.78–1.41)
Place of Residence
Urban	1.00	1.00
Rural	0.90 (0.82–0.99)^*	0.96 (0.86–1.07)
Geographic Region
Central	1.00	1.00
North	0.87 (0.80–0.94)^**	0.91 (0.83–0.99)^*
South	1.02 (0. 90–1.16)	1.03 (0.99–1.18)
Mother's Education
No education	1.00	1.00
Primary	1.41 (1.08–1.85)^*	1.33 (1.00–1.78)^*
Secondary	1.01 (0.80–1.29)	0.96 (0.73–1.25)
Higher	1.11 (0.87–1.42)	0.79 (0.60–1.06)
Husband's Education
No education	1.00	1.00
Primary	1.14 (0.82–1.59)	1.21 (0.84–1.73)
Secondary	1.02 (0.74–1.39)	1.16 (0.81–1.65)
Higher	1.22 (0.89–1.68)	1.17 (0.81–1.68)
Employment
Unemployed	1.00	1.00
Employed	1.58 (1.43–1.75)^***	1.34 (1.19–1.51)^***
Place of Delivery
Public sector	1.00	1.00
Private sector	1.17 (1.08–1.26)^***	1.04 (0.95–1.14)
Wealth Index
Poorest	1.00	1.00
Poorer	0.94 (0.84–1.05)	0.94 (0.84–1.06)
Middle	1.20 (1.07–1.34)^***	1.27 (1.13–1.43)^***
Richer	1.30 (1.16–1.45)^***	1.32 (1.16–1.51)^***
Richest	1.47 (1.30–1.65)^***	1.39 (1.20–1.62)^***
Parity in Last 5 years
1	1.00	1.00
2	0.86 (0.79–0.93)^***	0.81 (0.75–0.88)^***
≥ 3	1.04 (0.90–1.18)	0.82 (0.70–0.95)^*
Age at First Birth, y
12–18	1.00	1.00
19–24	1.10 (0.98–1.22)	1.14 (1.02–1.28)^*
25–30	1.72 (1.52–1.94)^***	1.75 (1.52–2.01)^***
> 30	4.69 (3.93–5.61)^***	4.58 (3.77–5.55)^***
Birth Weight, g
Normal (2500–3999)	1.00	1.00
Low/High (< 2500 or ≥ 4000)	1.55 (1.43–1.68)^***	1.53 (1.40–1.66)^***
Birth Multiplicity
Singleton birth	1.00	1.00
Multiple birth	5.47 (4.38–6.82)^***	5.60 (4.20–7.09)^***

Abbreviations: aOR, adjusted odds ratio (for all covariates under analysis); CI, confidence interval; OR, odds ratio.
↵^*P< .05; ^** P< .01; ^*** P< .001.