Maternal complications after cesarean section by obstetric facility type in Japan: A claims-based cohort study
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Aim
Little is known about patient safety in a less consolidated obstetric system where various facilities, such as perinatal medical centers (PMCs), general hospitals, and clinics, collaborate under risk-based role differentiation. We aimed to compare maternal complications after cesarean section by facility type across area types (rural, provincial, and metropolitan) in Hokkaido, Japan.
Methods
This retrospective cohort study used insurance claims data from Hokkaido (2018–2025). Two comparisons were conducted for a composite outcome of postpartum hemorrhage, infection, and thrombosis: a two-category comparison (PMC vs. non-PMC, combining general hospitals and clinics) across all areas, with an interaction term between facility and area type; a three-category comparison (PMC vs. general hospital vs. clinic) restricted to metropolitan areas. Generalized estimating equations with a Poisson distribution, accounting for clustering within facilities, were applied to estimate risk ratios.
Results
A total of 1,822 participants underwent cesarean section. PMCs were associated with lower maternal complication rates compared to non-PMC facilities (adjusted RR 0.37, 95% CI 0.16–0.88 in rural areas; adjusted RR 0.20, 95% CI 0.11–0.37 in provincial areas). In metropolitan areas, PMCs and general hospitals were associated with lower maternal complication rates compared to clinics (PMC vs clinic: adjusted RR 0.42, 95% CI 0.18–0.97; general hospital vs clinic: adjusted RR 0.25, 95% CI 0.09–0.70).
Conclusions
Higher-level facilities were associated with lower maternal complication rates after cesarean section in Japan. These findings provide important evidence for regional consolidation of obstetric care.
