Cesarean Delivery Rates Vary Up to 15-Fold in US Hospitals

Steven Fox

March 06, 2013

Rates of cesarean deliveries vary as much as 15-fold among US hospitals, according to retrospective data from nearly 600 hospitals. The researchers who conducted the study say vast differences in practice patterns are likely driving the costly use of the procedures, and they suggest several possible strategies for reducing those variations.

The study is authored by Katy Backes Kozhimannil, PhD, assistant professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, and colleagues, and appears in the March issue of Health Affairs.

They note that rates of cesarean deliveries increased from 20.7% of all deliveries in 1996 to 32.8% in 2011.

"The rise in the cesarean rate is commonly attributed to several factors, including a higher rate of conditions that may necessitate cesarean delivery—such as multiple gestation, maternal obesity, preterm labor, gestational diabetes, or hypertension—as well as physicians' concerns about liability and malpractice," the authors write. "But evidence indicates that these factors do not fully account for the wide differences in cesarean rates observed across states and countries."

The authors say that gaining an understanding of what causes the variations might help identify policy options that can improve care.

Prior research focusing on variations in cesarean rates among hospitals have identified differences in practice patterns as a primary factor fueling the variations, the authors note. However, they add, those studies have looked at variations across geographic lines, rather than assessing the variations from a broader perspective.

"No prior study has reported hospital-level variations in cesarean delivery rates using recent, nationally representative data," they note.

Looking to do just that, these investigators assessed 2009 data from a list of 593 US hospitals generated from the Nationwide Inpatients Sample, part of the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Reducing Variations

The authors found that overall rates of cesarean delivery varied 10-fold among hospitals, ranging from 7.1% of deliveries in some hospitals to as much as to 69.9% in others.

In addition, for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied even more, ranging from 2.4% to 36.5%.

The authors note that cesarean deliveries cost considerably more than vaginal births and that Medicaid foots the bill for nearly half the births in the United States. That being the case, the investigators suggest that governments have a strong stake in reducing variations.

They offer 4 options that they see as promising for achieving that goal:

  • improving specialization and triage for maternity care,

  • increasing data collection and measurement of maternity care quality,

  • using Medicaid policy to improve hospital management practices in labor and delivery units, and

  • enhancing patient-centered decision-making for maternity care through public reporting.

The authors conclude, "These variations have important health and cost implications for state and federal public health agencies, the Centers for Medicare and Medicaid Services, state Medicaid programs, Medicaid managed care plans, hospitals, health care providers, and the four million American families that brought a newborn home from the hospital in 2009."

This work was supported in part by the University of Minnesota's Building Interdisciplinary Research Careers in Women's Health Program and the Minnesota Population Center, both funded through grants from the Eunice Kennedy Shriver National Institute for Child Health and Human Development. The authors have disclosed no relevant financial relationships.

Health Aff. 2013;32:527-535. Abstract