Objective To develop and validate a logistic regression model for analyzing the probability of caesarean section births, adjusted for clinical complexity, across public hospitals in Catalonia, and to identify deviations from expected caesarian section rates for benchmarking and quality improvement.

Methods This retrospective cohort study analyzed data from the Catalan National Health System’s Minimum Basic Data Set (CMBD-AH), including all deliveries in public hospitals from January 2018 to June 2024. A logistic regression model was constructed using maternal and obstetric factors such as age, obstetric history, and clinical conditions. The model was validated through calibration plots and receiver operating characteristic (ROC) curve analysis, achieving an area under the curve (AUC) of 0.803.

Results The analysis revealed variability in observed-to-expected caesarean section ratios across hospital complexity levels. Level III hospitals aligned closely with expected rates, reflecting adherence to clinical standards for high-complexity cases. Level I hospitals demonstrated significant variability, with 59.1% performing more cesareans than expected; smaller hospitals with fewer than 1,000 births exhibited the greatest deviation. The model highlighted both underperforming and overperforming institutions, offering actionable insights for resource allocation and policy interventions.

Conclusions The logistic regression model provides a robust framework for evaluating caesarean section practices, enabling fair comparisons between hospitals by adjusting for clinical complexity. It supports the identification of non-clinical factors influencing cesarean practices and offers a critical tool for quality improvement and optimizing maternal healthcare within Catalonia’s public health system.

The authors have declared no competing interest.

This study did not receive any funding

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study used only openly available human data sourced from the Catalan National Health System's Minimum Basic Data Set (CMBD-AH). This dataset is maintained under strict regulatory and ethical standards and is fully anonymized before being made accessible. The data were analyzed internally within the Catalan Health Service to support health planning and service improvement. As the data were anonymized and did not involve identifiable information, the study did not require ethics committee approval or patient consent. This approach aligns with the standard procedures within the healthcare administration for systematically assessing and improving healthcare provider performance in Catalonia.

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Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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All data produced in the present study are available upon reasonable request to the authors