The overall research goal of this project is to examine the variations in the use of Caesarian-section in Scotland and explore the determinant factors of the decision regarding the method of birth delivery.


Since the 1970s, there is a significant increase in the rate of caesarian sections across many developed countries, including the UK (Althabe, 2006; Information Centre, 2009). More specifically, in Scotland, the rate of Caesarean-sections has increased from 8.7% in 1976 to 32.4% in 2016 (ISD Scotland, 2016). Interestingly, new policies were introduced by NICE introduced new policies in November 2011, suggesting that Caesarian-section will be available even to women who are capable of giving birth naturally and that the operation will be elective if it is prearranged. However, Caesarean-section is costly (about £800 more than a regular delivery) and requires longer hospital stay and recovery.

Variations in C-Section rates

Wide variations in the rates of Caesarean-section have been documented across different countries, across different regions within the UK (as well as within a large variety of countries) and across healthcare providers. Moreover, aggregated data regarding the mode of delivery show considerable variations across Scottish NHS health boards. However, the variations that have been documented are not fully explained by differences in patient characteristics or needs.

Research aims

This research aims to:

  • Investigate the contribution of patient, clinical (at GP level) and hospital factors in the observed variations by using hierarchical models.
  • Examine the effect of NICE policies to the Caesarean-section rates by employing a synthetic control method.
  • Evaluate the Enhanced Recovery Pilot, which introduced a new regime for the treatment of patients after giving birth through Caesarean-section, with the key aim to reduce the mothers’ length of stay in hospital, while avoiding the need for follow-up treatments.
  • Integrate the analysis in a single framework by bringing the cost element into the project and explore the potential for more cost-effective delivery in maternity services.

Policy relevance

The high policy relevance that comes with this project is that information on medical practice and healthcare utilisation variations can be a very useful tool for auditing the relations between policy decisions and clinical decisions and can highlight important questions in concern of the efficiency, the equity and effectiveness of the healthcare system. Finally, they could reveal potential opportunities of reducing costs without compromising the quality of care.