Papers

Do obstetric complications explain high caesarean section rates among women over 30? A retrospective analysis

Jacqueline S Bell, research fellow ^a, Doris M Campbell, senior lecturer ^a, Wendy J Graham, professor ^a, Gillian C Penney, senior lecturer ^a, Mandy Ryan, Medical Research Council senior fellow ^b, Marion H Hall, consultant obstetrician ^a. 

^a Dugald Baird Centre for Research in Women's Health, Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen AB25 2ZL, ^b Health Economics Research Unit, University of Aberdeen, Aberdeen AB25 2ZD

Correspondence to: J S Bell j.bell{at}abdn.ac.uk

As a growing proportion of women delay childbearing into their later reproductive years, the risks and costs associated with advancing maternal age become increasingly important. Extensive evidence shows that both obstetric interventions and obstetric complications are more common among older women,¹ and it is often assumed that the interventions are a consequence of the complications. Delivery by caesarean section is one such intervention that is associated with maternal age and is of importance for public health. The extent to which the association is explained by obstetric complications is, however, not known. Martel et al showed that an association between maternal age and rates for primary caesarean section persisted after adjustment for induction of labour, epidural anaesthesia, meconium stained amniotic fluid, and fetal distress.² We aimed to build on this finding by considering a greater number of obstetric complications in a much larger population and with more detailed records.

	Methods and results

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We obtained our information from the Aberdeen Maternal and Neonatal Databank for all singleton deliveries to city residents aged at least 20 years during 1988-97; totalling 23 806 deliveries.³ We used logistic regression to obtain crude odds ratios for delivery by caesarean section among older women (age categories 30-31, 32-33, 34-35, 36-37, 38-39, and 40 and over) compared with a reference group of women aged 20-29 years. Primiparous and multiparous women were analysed separately, as were elective and emergency caesarean sections. We investigated the potential confounders of the association between age and outcome, and we also checked for any evidence of effect modification with the same variablesmaternal sociodemographic characteristics and obstetric history.

We selected the obstetric complications and interventions associated with a higher probability of caesarean section, which might explain the association with age (see figure on web). Using multivariate logistic regression we adjusted the crude odds ratios for these variables, also controlling for any identified confounders and stratifying by effect modifiers.

The association between maternal age and caesarean section varied depending on how the baby presented at delivery and whether a woman had previously had a caesarean. Among women who had not previously had a caesarean section and whose babies presented normally at delivery there was a strong and consistent relation between maternal age and delivery by caesarean section that remained after controlling for relevant obstetric complications and identified confounders (see figure on web). Among women who had had a previous caesarean section or whose babies presented abnormally the association between maternal age and both elective and emergency sections was greatly reduced (results not shown).

	Comment

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The observed relation between maternal age and caesarean section cannot be explained by the obstetric complications we considered. They add to previous findings by including greater numbers of obstetric complications and deliveries in the analysis. This raises the question of why rates for caesarean section are high among older mothers, and whether they may be explained by physiological or other factors we have been unable to control for. Medical causes that have been suggested include reduced uterine function and pelvic compliance among older women.⁴ However we expected that length of labour would act as a proxy for these factors in our analysis. Many authors have identified physician and maternal preference in the higher section rates among older women, ^{1 5} and our results would support this speculation. Further investigation is needed into women's views about increased intervention, the variation in rates for caesarean section among obstetricians, and how maternal age influences both of these factors.

	Acknowledgments

This project was funded by the Chief Scientist Office of the Scottish Executive; the executive accepts no responsibility for the information provided or the views expressed.

Contributors: JSB analysed the data and conducted the preliminary interpretation of the results; she was responsible for drafting and revising the paper. DMC, WJG, MHH, GCP, and MR designed the study, secured the funding for the project, and advised throughout on the conduct and interpretation of the analysis. WJG identified the need for the study. All authors helped revise the paper and will act as guarantors.

	Footnotes

Competing interests: None declared.

Figure showing odds ratios for delivery by caesarean section in women with no history of such sections appears on the BMJ's website

	References

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1.	Berkowitz GS, Skovron ML, Lapinski RH, Berkowitz RL. Delayed childbearing and the outcome of pregnancy. N Engl J Med 1990; 322: 659-664[Abstract].
2.	Martel M, Wacholder S, Lippman A, Brohan J, Hamilton E. Maternal age and primary cesarean section rates: a multivariate analysis. Am J Obstetr Gynecol 1987; 156: 305-308[Medline].
3.	Samphier M, Thompson B. The Aberdeen Maternal and Neonatal Databank. In: Mednick SA, Baert AE, eds. Prospective longitudinal research. London: Oxford University Press, 1981.
4.	Rosenthal AN, Paterson-Brown S. Is there an incremental rise in the risk of obstetric intervention with increasing maternal age? Br J Obstetr Gynaecol 1998; 105: 1064-1069[Medline].
5.	Leitch CR, Walker JJ. The rise in caesarean section rate: the same indications but a lower threshold. Br J Obstetr Gynaecol 1998; 105: 621-626[Medline].

(Accepted 1 December 2000)