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Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study

BMJ 2010; 341 doi: (Published 06 October 2010) Cite this as: BMJ 2010;341:c5065

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  1. Fiona Bragg, specialty registrar in public health12,
  2. David A Cromwell, senior lecturer14,
  3. Leroy C Edozien, consultant obstetrician and gynaecologist3,
  4. Ipek Gurol-Urganci, lecturer14,
  5. Tahir A Mahmood, vice president4,
  6. Allan Templeton, professor of obstetrics and gynaecology4,
  7. Jan H van der Meulen, professor of clinical epidemiology14
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2NHS City and Hackney, London, UK
  3. 3Maternal and Fetal Health Research, St Mary’s Hospital, Manchester, UK
  4. 4Royal College of Obstetricians and Gynaecologists, London, UK
  1. Correspondence to: D A Cromwell, Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK david.cromwell{at}
  • Accepted 26 July 2010


Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors.

Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model.

Setting 146 English NHS trusts.

Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008.

Main outcome measure Rate of caesarean sections per 100 births (live or stillborn).

Results Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section.

Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.


  • We thank the Department of Health for providing the hospital episode statistics data used in this study.

  • Contributors: DAC, LCE, TAM, AT, and JHvdM conceived and designed the study; FB, IG-U, and DAC conducted the statistical analyses; FB and DAC wrote the manuscript; LCE, IG-U, TAM, AT, and JHvdM commented on drafts. DAC is guarantor.

  • Funding: JHvdM received a national public health career scientist award from the Department of Health and NHS research and development programme.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.”

  • Ethical approval: Not required for the analysis of anonymised routine data for service evaluation.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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