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DOI: 10.1055/s-0041-1736538
A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States
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Abstract
Objectives Cesarean rates vary widely across the U.S. states; however, little is known about the causes and implications associated with these variations. The objectives of this study were to quantify the contribution of the clinical and nonclinical factors in explaining the difference in cesarean rates across states and to investigate the associated health outcome of cesarean variations.
Study Design Using the Hospital Cost and Utilization Project State Inpatient Databases, this retrospective study included all nonfederal hospital births from Wisconsin, Florida, and New York. A nonlinear extension of the Oaxaca–Blinder method was used to decompose the contributions of differences in characteristics to cesarean variations between these states. The risk factors for cesarean delivery were identified using separate multivariable logistic regression analysis for each State.
Results The difference in clinical and nonclinical factors explained a substantial (~46.57–65.45%) proportion of cesarean variations between U.S. states. The major contributors of variation were patient demographics, previous cesareans, hospital markup ratios, and social determinants of health. Cesarean delivery was significantly associated with higher postpartum readmissions and unplanned emergency department visits, greater lengths of stay, and hospital costs across all states.
Conclusion Although a proportion of variations in cesarean rates can be explained by the differences in risk factors, the remaining unexplained variations suggest differences in practice patterns and imply potential quality concerns. Since nonclinical factors are likely to play an important role in cesarean variation, we recommend targeted initiatives increasing access to maternal care and improving maternal health literacy.
Key Points
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Cesarean rates vary widely almost two folds within U.S. states.
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The difference in risk factors explained substantial (~46.57–65.45%) of the cesarean variations.
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Mother race, hospital factors, and social determinants comprised major proportion of explained variation.
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Adverse outcomes and increased expenditures were associated with cesarean than vaginal delivery.
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Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries are reduced.
Publikationsverlauf
Eingereicht: 21. August 2021
Angenommen: 13. September 2021
Artikel online veröffentlicht:
19. Oktober 2021
© 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
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References
- 1 Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK. Society for Maternal-Fetal Medicine Health Policy Committee. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol 2016; 214 (02) 153-163
- 2 Alfandre DJ. “I'm going home”: discharges against medical advice. Mayo Clin Proc 2009; 84 (03) 255-260
- 3 Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014. PLoS One 2016; 11 (02) e0148343
- 4 Collier AY, Molina RL. Maternal mortality in the united states: Updates on trends, causes, and solutions. Neoreviews 2019; 20 (10) e561-e574
- 5 Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLoS One 2016; 11 (02) e0148343
- 6 Volpe FM. Correlation of Cesarean rates to maternal and infant mortality rates: an ecologic study of official international data. Rev Panam Salud Publica 2011; 29 (05) 303-308
- 7 Ecker JL, Frigoletto Jr FD. Cesarean delivery and the risk-benefit calculus. N Engl J Med 2007; 356 (09) 885-888
- 8 Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med 2018; 15 (01) e1002494
- 9 Liu S, Heaman M, Joseph KS. et al; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005; 105 (04) 836-842
- 10 Guise JM, Denman MA, Emeis C. et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010; 115 (06) 1267-1278
- 11 Li H, Ye R, Pei L, Ren A, Zheng X, Liu J. Caesarean delivery, caesarean delivery on maternal request and childhood overweight: a Chinese birth cohort study of 181 380 children. Pediatr Obes 2014; 9 (01) 10-16
- 12 van Berkel AC, den Dekker HT, Jaddoe VWV. et al. Mode of delivery and childhood fractional exhaled nitric oxide, interrupter resistance and asthma: the Generation R study. Pediatr Allergy Immunol 2015; 26 (04) 330-336
- 13 Cegolon L, Mastrangelo G, Campbell OM. et al. Length of stay following cesarean sections: a population based study in the Friuli Venezia Giulia region (North-Eastern Italy), 2005-2015. PLoS One 2019; 14 (02) e0210753
- 14 Corry MP, Delbanco SF, Miller HD. The cost of having a baby in the United States. Truven Health Analytics. Accessed October 1, 2021 at: https://www.nationalpartnership.org/our-work/resources/health-care/maternity/archive/the-cost-of-having-a-baby-in-the-us.pdf
- 15 National Health Policy Forum. Caesar's ghost: the effect of the rising rate of C-sections on health care costs and quality. Accessed October 1, 2021 at: https://www.nhpf.org/library/forum-sessions/FS_03-30-12_CSections.pdf
- 16 Maternal, infant, and child health. Accessed October 1, 2021 at: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
- 17 Gibbons L, Belizan JM, Lauer JA, Betran AP, Merialdi M, Althabe F. Inequities in the use of cesarean section deliveries in the world. Am J Obstet Gynecol 2012; 206 (04) 331.e1-331.e19
- 18 Hoxha I, Syrogiannouli L, Luta X. et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis. BMJ Open 2017; 7 (02) e013670
- 19 Oner C, Catak B, Sütlü S, Kilinç S. Effect of social factors on cesarean birth in Primiparous women: a cross sectional study (social factors and cesarean birth). Iran J Public Health 2016; 45 (06) 768-773
- 20 Brick A, Layte R, Nolan A, Turner MJ. Differences in nulliparous caesarean section rates across models of care: a decomposition analysis. BMC Health Serv Res 2016; 16 (01) 239
- 21 Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood) 2013; 32 (03) 527-535
- 22 Baicker K, Buckles KS, Chandra A. Geographic variation in the appropriate use of cesarean delivery. Health Aff (Millwood) 2006; 25 (5, suppl1): w355-w367
- 23 Podulka J, Stranges E, Steiner C. Hospitalizations related to childbirth, 2008. Accessed October 1, 2021 at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb110.jsp
- 24 Henke RM, Wier LM, Marder WD, Friedman BS, Wong HS. Geographic variation in cesarean delivery in the United States by payer. BMC Pregnancy Childbirth 2014; 14 (01) 387
- 25 Hoxha I, Syrogiannouli L, Braha M, Goodman DC, da Costa BR, Jüni P. Caesarean sections and private insurance: systematic review and meta-analysis. BMJ Open 2017; 7 (08) e016600
- 26 Hanley GE, Janssen PA, Greyson D. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Obstet Gynecol 2010; 115 (06) 1201-1208
- 27 Agency for Healthcare Research and Quality. Evidence-based practice center systematic review protocol. Project title: strategies to reduce cesarean. Accessed October 1, 2021 at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cesarean-birth-2010_research-protocol.pdf
- 28 Reducing early elective deliveries in Medicaid and CHIP. Accessed October 1, 2021 at: https://www.medicaid.gov/medicaid/quality-of-care/downloads/eed-brief.pdf
- 29 Johnson K. Addressing women's health needs and improving birth outcomes: results from a peer-to-peer state Medicaid learning project. Issue Brief (Commonw Fund) 2012; 21 (01) 1-19
- 30 Antonisse L, Garfield R, Rudowitz R, Artiga S. The effects of Medicaid expansion under the ACA: updated findings from a literature review. Accessed October 1, 2021 at: https://files.kff.org/attachment/Issue-Brief-The-Effects-of-Medicaid-Expansion-Under-the-ACA-Updated-Findings-from-a-Literature-Review
- 31 Ranji U, Gomez I, Salganicoff A. Expanding postpartum Medicaid coverage. Accessed October 1, 2021 at: https://www.kff.org/womens-health-policy/issue-brief/expanding-postpartum-medicaid-coverage/
- 32 Kuklina EV, Whiteman MK, Hillis SD. et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J 2008; 12 (04) 469-477
- 33 Uniform Data System (UDS) Mapper. Health Resources and Services Administration. Bureau of Primary Health Care, Jon Snow, Inc., American Academy of Family Physicians, and Blue Raster LLC. Accessed Date October 9, 2021 at: https://udsmapper.org/zip-code-to-zcta-crosswalk/
- 34 Rogers CR, Blackburn BE, Huntington M. et al. Rural-urban disparities in colorectal cancer survival and risk among men in Utah: a statewide population-based study. Cancer Causes Control 2020; 31 (03) 241-253
- 35 Bateman BT, Mhyre JM, Hernandez-Diaz S. et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013; 122 (05) 957-965
- 36 Gyamfi-Bannerman C, Srinivas SK, Wright JD. et al. Postpartum hemorrhage outcomes and race. Am J Obstet Gynecol 2018; 219 (02) 185.e1-185.e10
- 37 Leonard SA, Main EK, Scott KA, Profit J, Carmichael SL. Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Ann Epidemiol 2019; 33: 30-36
- 38 Wu Y, Kataria Y, Wang Z, Ming WK, Ellervik C. Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2019; 19 (01) 360
- 39 Poobalan AS, Aucott LS, Gurung T, Smith WCS, Bhattacharya S. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women–systematic review and meta-analysis of cohort studies. Obes Rev 2009; 10 (01) 28-35
- 40 State Population Totals and Components of Change: 2010–2019. Accessed October 1, 2021 at: https://www.census.gov/data/tables/time-series/demo/popest/2010s-state-total.html
- 41 Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol 2016; 215 (01) 113.e1-113.e10
- 42 Healthcare Cost and Utilization Project. Cost-to-charge ratio files. Accessed May 4, 2019 at: https://www.hcup-us.ahrq.gov/db/state/costtocharge.jsp
- 43 Fairline RW. An extension of the Blinder-Oaxaca decomposition technique to logit and probit models. J Econ Soc Meas 2005; 30 (04) 305-316
- 44 Desai G, Anand A, Modi D. et al. Rates, indications, and outcomes of caesarean section deliveries: A comparison of tribal and non-tribal women in Gujarat, India. PLoS One 2017; 12 (12) e0189260
- 45 Wehby GL, Murray JC, McCarthy AM, Castilla EE. Racial gaps in child health insurance coverage in four South American countries: the role of wealth, human capital, and other household characteristics. Health Serv Res 2011; 46 (6, pt. 2): 2119-2138
- 46 Fagerland MW, Hosmer DW, Bofin AM. Multinomial goodness-of-fit tests for logistic regression models. Stat Med 2008; 27 (21) 4238-4253
- 47 Little SE, Orav EJ, Robinson JN, Caughey AB, Jha AK. The relationship between variations in cesarean delivery and regional health care use in the United States. Am J Obstet Gynecol 2016; 214 (06) 735.e1-735.e8
- 48 Min CJ, Ehrenthal DB, Strobino DM. Investigating racial differences in risk factors for primary cesarean delivery. Am J Obstet Gynecol 2015; 212 (06) 814.e1-814.e14
- 49 Lin HC, Sheen TC, Tang CH, Kao S. Association between maternal age and the likelihood of a cesarean section: a population-based multivariate logistic regression analysis. Acta Obstet Gynecol Scand 2004; 83 (12) 1178-1183
- 50 Sheen JJ, Wright JD, Goffman D. et al. Maternal age and risk for adverse outcomes. Am J Obstet Gynecol 2018; 219 (04) 390.e1-390.e15
- 51 Cleary-Goldman J, Malone FD, Vidaver J. et al; FASTER Consortium. Impact of maternal age on obstetric outcome. Obstet Gynecol 2005; 105 (5, pt. 1): 983-990
- 52 Guglielminotti J, Deneux-Tharaux C, Wong CA, Li G. Hospital-level factors associated with anesthesia-related adverse events in cesarean deliveries, New York State, 2009–2011. Anesth Analg 2016; 122 (06) 1947-1956
- 53 Sebastião YV, Womack L, Vamos CA. et al. Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida. Am J Obstet Gynecol 2016; 214 (01) 123.e1-123.e18
- 54 Marshall NE, Guild C, Cheng YW, Caughey AB, Halloran DR. Racial disparities in pregnancy outcomes in obese women. J Matern Fetal Neonatal Med 2014; 27 (02) 122-126
- 55 Hollard AL, Wing DA, Chung JH. et al. Ethnic disparity in the success of vaginal birth after cesarean delivery. J Matern Fetal Neonatal Med 2006; 19 (08) 483-487
- 56 Bryant AS, Washington S, Kuppermann M, Cheng YW, Caughey AB. Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates. Paediatr Perinat Epidemiol 2009; 23 (05) 454-462
- 57 Rosenthal L, Lobel M. Explaining racial disparities in adverse birth outcomes: unique sources of stress for Black American women. Soc Sci Med 2011; 72 (06) 977-983
- 58 Kingdon C, Downe S, Betran AP. Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies. PLoS One 2018; 13 (09) e0203274
- 59 Kozhimannil KB, Hardeman RR, Alarid-Escudero F, Vogelsang CA, Blauer-Peterson C, Howell EA. Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery. Birth 2016; 43 (01) 20-27
- 60 Currie J, MacLeod WB. Diagnosis and unnecessary procedure use: evidence from C-section. Accessed October 1, 2021 at: https://www.nber.org/system/files/working_papers/w18977/revisions/w18977.rev0.pdf
- 61 Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118 (01) 29-38
- 62 MacDorman MF, Declercq E. Trends and state variations in out-of-hospital births in the United States, 2004-2017. Birth 2019; 46 (02) 279-288
- 63 Glazer KB, Danilack VA, Werner EF, Field AE, Savitz DA. Elucidating the role of overweight and obesity in racial and ethnic disparities in cesarean delivery risk. Ann Epidemiol 2020; 42: 4-11.e4
- 64 Public Use Data File. Accessed October 1, 2021 at: https://www.npdb.hrsa.gov/resources/publicData.jsp
- 65 Durrance CP, Hankins S. Medical malpractice liability exposure and OB/GYN physician delivery decisions. Health Serv Res 2018; 53 (04) 2633-2650