Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries

OBJECTIVE: The aim of this study is to determine the odds of caesarean section in all births in teaching hospitals as compared with non-teaching hospitals. SETTING: Over 3600 teaching and non-teaching hospitals in 22 countries. We searched CINAHL, The Cochrane Library, PubMed, sciELO, Scopus and Web of Science from the beginning of records until May 2020. PARTICIPANTS: Women at birth. Over 18.5 million births. INTERVENTION: Caesarean section. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures are the adjusted OR of caesarean section in a variety of teaching hospital comparisons. The secondary outcome is the crude OR of caesarean section in a variety of teaching hospital comparisons. RESULTS: In adjusted analyses, we found that university hospitals have lower odds than non-teaching hospitals (OR=0.66, 95% CI 0.56 to 0.78) and other teaching hospitals (OR=0.46, 95% CI 0.24 to 0.89), and no significant difference with unspecified teaching status hospitals (OR=0.92, 95% CI 0.80 to 1.05, τ2=0.009). Other teaching hospitals had higher odds than non-teaching hospitals (OR=1.23, 95% CI 1.12 to 1.35). Comparison between unspecified teaching hospitals and non-teaching hospitals (OR=0.91, 95% CI 0.50 to 1.65, τ2=1.007) and unspecified hospitals (OR=0.95, 95% CI 0.76 to 1.20), τ2<0.001) showed no significant difference. While the main analysis in larger sized groups of analysed studies reveals no effect between hospitals, subgroup analyses show that teaching hospitals carry out fewer caesarean sections in several countries, for several study populations and population characteristics. CONCLUSIONS: With smaller sample of participants and studies, in clearly defined hospitals categories under comparison, we see that university hospitals have lower odds for caesarean. With larger sample size and number of studies, as well as less clearly defined categories of hospitals, we see no significant difference in the likelihood of caesarean sections between teaching and non-teaching hospitals. Nevertheless, even in groups with no significant effect, teaching hospitals have a lower or higher likelihood of caesarean sections in several analysed subgroups. Therefore, we recommend a more precise examination of forces sustaining these trends. PROSPERO REGISTRATION NUMBER: CRD42020158437.