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Hospital-Level Variation in Cesarean Delivery Rates

Summary and Comment |
April 11, 2013

Hospital-Level Variation in Cesarean Delivery Rates

  1. Allison Bryant, MD, MPH

Rates vary vastly among U.S. hospitals, raising concerns about disparities in obstetric care.

  1. Allison Bryant, MD, MPH

The incidence of cesarean deliveries has risen from 21% of all births in 1996 to 33% in 2011. This trend has been attributed to changes in maternal, fetal, societal, and healthcare-related factors, only some of which reflect actual clinical risk. Recognizing the additional cost to the healthcare system of cesarean versus vaginal delivery as well as the potential role of hospitals in reining in the cesarean rate, health-policy researchers sought to quantify hospital-level variation in frequency of cesarean delivery.

From a national sample of 1050 hospitals, records of 593 hospitals with ≥100 deliveries in 2009 were analyzed. Hospital-wide rates of cesarean deliveries ranged from 7% to 70% (mean, 33%). Among women with low-risk pregnancies (full-term, singleton, cephalic presentation, and no cesarean history), rates varied from 2% to 36% (mean, 12%). Mean hospital-level rates were generally similar across the categories of hospital size, location (rural or urban), and teaching or nonteaching; however, rates varied greatly within each category.

Comment

These hospital-to-hospital differences in use of cesarean delivery are striking — low-risk women might be 15 times more likely to undergo the procedure at one U.S. hospital than another. Such variation raises concern about disparities in obstetric care from one healthcare setting to another. Although differences in patient preferences or other unmeasured patient characteristics might contribute to some variability in cesarean rates, they are unlikely to explain the wide discrepancies observed in this study. Hospitals and health-policy makers have an obligation to influence obstetric care in ways that stem the rising tide of cesarean deliveries (e.g., using night-float scheduling or hospitalists to minimize pressure to complete deliveries during the day). Such interventions should include better support for women (particularly those at low risk for complicated deliveries) to achieve vaginal delivery when appropriate, as well as more-conscious alignment of financial and practice incentives toward the goal of vaginal delivery.

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