Regional variation in caesarean section deliveries in Germany – secondary analysis of a large pharmacoepidemiological database

Background: Caesarean sections (CS) are on the increase worldwide. Causes of this increase are multifactorial and not fully understood yet. Regional variation in the percentage of CS supports the notion of local customs in the health care sector as well as preferences among women. Methods: We analysed a database consisting of claims data of four German health insurance companies for the years 2004–2006. The database (German Pharmacoepidemiological Research Database – GePaRD) includes 14 million insurants (approximately 17% of the German population) and is fairly representative in terms of sex and age distribution for the German population. On the regional level, it includes between 9% and 21% of the population of a given federal state with the exception of Bremen (53%). ICD-10 codes indicating CS were extracted and divided by all deliveries coded in hospital data. Results: The percentage of CS in the database was 29.1% in 2004, 29.2% in 2005 and 29.9% in 2006. Estimates constructed to reflect the number of CS in the total population in Germany were only slightly different. Percentages observed in the database were somewhat higher than in the official statistics, but the numbers converged over time (29.1% vs. 26.8% in 2004, 29.2% vs. 27.5% in 2005 and 29.9% vs. 28.6% in 2006). CS fractions observed in the database varied substantially across the federal states, with a main difference between former East and West Germany (around 22% in the former and 30% in the latter). Applying the same age standard (German population in 2006) across the federal states reduced the difference only partially. Conclusions: Fifteen years after reunification of Germany, CS practices are substantially different in both former parts, with a 1.4 times higher fraction in federal states of former West Germany. These results stress the importance of other than strictly medical aspects in determing CS rates.