The problem with epidemiological associations is the wide variety of things which may be driving them. For example, a new study reports an association between hospital geographic location and the variation in primary cesarean delivery rates in the United States.
This phenomena is not limited to the United States, a study published in the European Journal of Public Health reports evidence of local drivers of cesarean rates. How much do all these factors matter? In the cesarean study, almost 40% of the variation in adjusted relative risk for primary cesarean — in plain terms, these factors mattered quite a bit.
The question is, what are these local drivers?
We do have evidence of local practice patterns driving medical decisions, and our cesarean study shows variations in induction rates and delivery during weekdays. But, as the cesarean study points out, medical practice is not the only thing which varies by location.
Hospital location was also associated with rates of pre-pregnancy obesity and other medical conditions. We know womens’ overall health varies by community. Factors such as poverty, air quality, and access to food and safe exercise mean some communities are simply more difficult places to be healthy.
Hospital location was associated with proportion of ethnic subgroups. In public health the assumption is ethnic subgroups may be proxies for cultural group-specific priorities in medical decision making. In the cesarean study, the contribution of “ethnicity” was up to up to 15% of the variation – while the effect was always there, the impact of it changed in different regions.
What does all this mean?
Can I suggest this means high cesarean rates are a multi-factorial problem. There is no single cause, and therefore no single “problem” which can be fixed to lower the rate.
Yes, improvements in evidence-based medical decision making are needed. But so are improvements in other drivers of community health; and changes in women’s medical decision making; and probably other things which we haven’t discussed in this post.
So think about your community. Are all these areas being addressed? If so, how? If not, why?