Cesarean Delivery Rates Vary Widely Among US Hospitals

A nationwide study in the United States shows that cesarean section delivery rates range from as low as 7% to as high as 70% in US hospitals, suggesting a possible quality-of-care problem.

Researchers at the University of Minnesota (Minneapolis, USA) analyzed inpatient claims data from 593 hospitals with at least 100 deliveries included in the 2009 Nationwide Inpatient Sample, which covered about 20% of all US centers. The researchers found that cesarean rates varied tenfold across hospitals, from 7.1% to 69.9%. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteen-fold, from 2.4% to 36.5%.

The mean cesarean delivery rate across the hospitals was 33%, and did not differ by number of beds, teaching status, or location categories, although rates varied widely within each category. Small and rural hospitals showed slightly more variability, while teaching hospitals showed less. The caesarean section rate among lower-risk pregnancies (term, singleton, and vertex pregnancies without prior cesarean delivery) was lower at 12% percent, but showed even greater variation between hospitals than the overall rate; again, ranges were somewhat greater at small and rural hospitals but less among teaching hospitals.

The researchers found that the magnitude of the variation was more than could be accounted for by case mix and overall volume of deliveries, but none of the factors appeared to explain much of the overall variation. Women asking for cesarean sections accounted for too small a percentage of the deliveries to drive the variations either. The researchers suggested that practice patterns are likely the driver, and one that ought to be the focus of policy interventions. The study was published in the March 2013 issue of Health Affairs.

“We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status,” concluded lead author Katy Backes Kozhimannil, PhD, and colleagues. “The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals, and policymakers.”

“Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted,” added Dr. Kozhimannil. “We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.”

Among the solutions offered was better triage in maternity care, so that high-risk pregnancies go to hospitals that can manage them, while others go to licensed birth centers that focus on vaginal delivery. Another would be to start monitoring cesarean section rates as part of a hospital's quality of care reporting, perhaps tied to Medicaid payments, and perhaps with public reporting.

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