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The “Proportion of deliveries by primary cesarean section” is an indicator that can be used to assess the quality of care provided to mothers giving birth. Hospitals and health systems are often compared based on this indicator, since lower values may reflect more appropriate clinical practice and that some cesarean sections may be performed for “non-medical reasons.”

Data show a slight reduction in the proportion of deliveries by primary cesarean section in Italy from 2015 (25%) to 2021 (22%). The Ministry of Health Decree No. 70 of April 2, 2015, on hospital care standards establishes a maximum threshold for the proportion of primary cesarean sections that varies based on the type of hospital, but which must not exceed 25%.

Comparisons between hospitals could, however, be distorted if the possible different distribution of patient risk factors for cesarean section were not taken into account. C-sections are indicated in many clinical situations, such as placental or cord complications, fetal distress, HIV infection, and fetal-pelvic disproportion. Furthermore, sociodemographic differences or differences in the availability of services for high-risk pregnancies increase the likelihood of a cesarean section.

The primary cesarean section indicator is calculated as the proportion of a woman’s first cesarean section births.

Since women with a previous cesarean birth are less likely to give birth vaginally, the indicator “Proportion of vaginal births in women with a previous cesarean birth” was calculated separately.

This indicator measures vaginal births performed in a hospital setting among women who have previously given birth by cesarean section. Data show a proportion of vaginal births after previous cesarean sections of around 10.5% between 2018 and 2021.

Acute severe maternal morbidity, or near miss, indicates a serious, potentially fatal obstetric complication and can be considered a valid indicator of the quality of obstetric healthcare, which has recently gained increasing importance, particularly in socially advanced countries with low maternal mortality ratios. The severe maternal morbidity rate (SMMR), i.e., the ratio of the number of near misses to the total number of births, is widely used internationally as a measure of maternal outcomes.

The extreme heterogeneity of inclusion and classification criteria for near misses, however, limits the ability to use this indicator for international comparisons. According to estimates by the World Health Organization, the prevalence of severe maternal morbidity worldwide varies significantly depending on the definition of near miss, ranging from 0.01% to 8.2%.

Two distinct indicators were calculated to measure serious maternal complications during childbirth and the postpartum period: • Serious maternal complications during childbirth and the postpartum period, which measures the proportion of serious maternal complications occurring within 42 days after childbirth; the exposure considered is the hospital facility; • Pregnancy complications observed during childbirth and the postpartum period, which measures the proportion of serious maternal complications occurring within 42 days after childbirth; the exposure considered is the area of residence. In both cases, both clinical criteria, based on specific pathological conditions, and criteria based on specific procedures and interventions, were used to define serious maternal complications. Furthermore, the indicator “Hospital readmissions within 42 days of admission for childbirth” was calculated, i.e., the proportion of hospital admissions for childbirth followed within 42 days by at least one acute hospital admission.

This indicator also aims to assess the frequency of hospital readmissions following childbirth. Measuring these indicators could highlight any differences in the quality of obstetric care provided by different local hospitals.

When comparing hospitals, it should be noted that the magnitude of the differences found could be influenced by both under-reporting and frequent errors in coding diagnoses, procedures, and interventions in hospital discharge forms. 1 The value of the indicators may vary between local areas and hospitals; this phenomenon, in addition to the different quality of care, may be caused by the heterogeneous distribution, due to case mix, of various risk factors such as the woman’s age and health.

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Birth

Cesarean section

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