Variation in elective primary cesarean delivery by patient and hospital factors

doi:10.1067/mob.2001.115496

American Journal of Obstetrics and Gynecology

Volume 184, Issue 7, June 2001, Pages 1521-1534

Poster presentation, presented at the Sixty-seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Kamuela, Hawaii, November 14-19, 2000.

https://doi.org/10.1067/mob.2001.115496 Get rights and content

Abstract

Objective: Our purpose was to describe variation in elective primary cesarean rates by nonclinical factors. Study Design: With use of California discharge data and American Hospital Association data for 1995, patients were classified into 13 mutually exclusive categories for elective primary cesarean delivery. With use of recursive partitioning algorithms, women in each category were then studied to determine whether nonclinical factors were associated with elective primary cesarean delivery. Results: A total of 463,196 women were delivered at 288 hospitals, and the elective primary cesarean delivery rate was 4.25% (19,664/463,196). Risk for elective primary cesarean delivery varied by clinical condition. The most discriminant risk factors were hospital type (malpresentation, multiple gestation, macrosomia, other hypertension), maternal age (antepartum bleeding, uterine scar, soft tissue disorder, preterm, unspecified), and teaching status (herpes, severe hypertension, unengaged head). Conclusion: This article presents methods that use administrative data to isolate and monitor the impact of nonclinical factors on the use of elective primary cesarean. (Am J Obstet Gynecol 2001;184:1521-34.)

Section snippets

Methods

The study population consisted of all patients who were delivered in 1995 in the State of California, as reported to the California Office of Statewide Health Planning and Development. Demographic characteristics (age ≥35 years, age <35 years, race/ethnicity, payor type: government, staff model health maintenance organization (HMO), private, other), and delivery hospital were identified from California Office of Statewide Health Planning and Development data. An American Hospital Association

Results

The final study population is described in Fig 1.

. Derivation of study population.

Of a total of 463,196 deliveries, 443,532 (95.75%) women labored, and 19,664 (4.25%) had an elective primary cesarean delivery. The total number of hospitals involved was 288, and the mean number of deliveries per hospital was 1838 ± 1367 (Table I). Per hospital, the mean elective primary cesarean delivery rate was 4.08% ± 1.61%. Some variation in median elective primary cesarean delivery rates existed by hospital

Comment

The purpose of our study was to examine the variation in elective primary cesarean delivery by patient demographic and hospital organizational factors. We found that there was variation in the likelihood of elective primary cesarean delivery for different subcategories of patients and that different clinical categories had different risk factors or “drivers.” Our study is different from previous studies in several ways. First, we focused on elective primary procedures. Although considerable

Acknowledgements

We thank Jeff Gornbein, PhD, from the Department of Biostatistics, University of California School of Public Health, for his expertise and advise regarding the use of recursive partitioning algorithms.

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Delivery of a macrosomic newborn also confers excess risk for the mother, including an increased risk of operative vaginal delivery (OVD), obstetric anal sphincter injury (OASIS), and postpartum hemorrhage (PPH) [3,4]. This association with birth injury, and in particular with shoulder dystocia and brachial plexus injury, has led to an increasing trend toward a planned delivery when fetal macrosomia is suspected, either by induction or an elective cesarean delivery [5,6]. However, the appropriate management in such cases remains unclear.
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A total of 7528 nulliparous labors were included (4989 in group 1 and 2539 in group 2a). The cesarean section rate was 15.1% overall (n = 1139), with 411 (8.2%) in group 1, and 728 (28.7%) in group 2a. Cesarean delivery rates rose with increasing birth weight in group 1, from 119 (6.3%) of 1886 infants weighing 3000–3499 g and 160 (8.5%) of 1892 weighing 3500–3999 g, to 19 (26.8%) of 71 weighing 4500–4999 g. Rates of cesarean delivery were significantly higher in induced labor (group 2a) for each birth-weight category, ranging from 202 (25.9%) of 781 weighing 3000–3499 g and 243 (27.0%) of 899 weighing 3500–3999 g, to 38 (48.1%) of 79 weighing 4500–4999 g (P < 0.01 for all).
In a setting with standardized management of labor, birth weight remains a significant determinant of mode of delivery.
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Nonetheless, given that our results were robust to adjusting for available clinical factors, the possibility exists that trends may be due to changes in physician practices or patient preferences. Indeed, nonclinical factors have been shown to contribute to variation in the primary cesarean delivery rate.22-26 Among the many nonclinical factors to consider would be the release of relevant guidelines or important documents that might affect primary cesarean delivery rates.
The national primary cesarean delivery rate increased until 2004, but after 2004, this rate cannot be tracked using Vital Statistics data. Additionally, it is unknown whether changes in the primary cesarean delivery rate reflect changes in the rate of labor attempts, labor success, or both. Here, using hospital discharge data, we examined national trends in primary cesarean deliveries, labor attempts, and labor success among women without prior cesarean delivery between 1990 and 2010.
This analysis of serial cross-sectional data from the National Hospital Discharge Survey used Joinpoint regression to assess trends over time and logistic regression with marginal effects to identify rates of change over time and adjust for demographic and clinical factors.
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The primary cesarean delivery rate continued to increase after 2004. Increases in the primary cesarean delivery rate after 2005 were driven by declines in labor success rates.
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The patient characteristics that influence cesarean rates are well known. However, there are many non clinical factors that also influence cesarean rates. Understanding these non clinical factors and how they can be changed to improve care is an important part of obstetrics. Provider staffing patterns, the types of providers and how information can be used to effectively change practice patterns are explored in this article.

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^☆: Reprint requests: Kimberly D. Gregory, MD, Cedars Sinai Medical Center, Department of Obstetrics and Gynecology, 8700 Beverly Blvd, Suite 160 West, Los Angeles, CA 90048.

^☆☆: Editors ’ note: This manuscript was revised after these discussions were presented.

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Transactions of the Sixty-Seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological SocietyVariation in elective primary cesarean delivery by patient and hospital factors☆,☆☆

Abstract

Section snippets

Methods

Results

Comment

Acknowledgements

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Jt Comm J Qual Improv

Births: final data for 1998

Natl Vital Stat Rep

Socioeconomic differences in rates of cesarean section

N Engl J Med

Racial/ethnic differences in the likelihood of cesarean delivery, California

Am J Public Health

Impact of risk-adjusting cesarean delivery rates when reporting hospital performance

JAMA

Cesarean section use and source of payment: an analysis of California hospital discharge abstracts

Am J Public Health

Consensus Development Conference on Cesarean Childbirth (Pub. No. 82:2067)

Understanding geographic variations in health care delivery

N Engl J Med

Transactions of the Sixty-Seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
Variation in elective primary cesarean delivery by patient and hospital factors☆,☆☆