Abstract
Unexpected Newborn Complication Rates (UNC) have been proposed as a balancing measure of neonatal implications of maternal-focused obstetric quality measures. The objective of this study was to investigate the relationship between county-level cesarean delivery rates among nulliparous women with term, vertex-presenting singletons (NTSV) and severe UNCs. This observational study used 2015-2017 county-level birth certificate data. The outcome was rate of severe UNC among term, live-born infants; complications included neonatal death, 5-minute Apgar ≤3, assisted ventilation ≥6 hours, serious neurologic complication/seizure, or neonatal transfer. For counties with greater than 1,000 term livebirths, the rate of severe UNC was compared to the NTSV cesarean delivery rate. Linear regressions weighted by county delivery volume estimated the association with and without adjustment for county-level factors. A subgroup analysis was performed excluding counties with NTSV rates >2 standard deviations (SD) from the mean. The analysis was conducted using data from 1,044 counties and representing 9,303,008 live births of term singletons. NTSV cesarean delivery rates ranged from 0.1 to 51.4 per 100 live births (mean 23.7, SD 6.0 per 100 live births). Severe UNC rates ranged from 0.6 to 88.7 per 1,000 live births (median 13.3, interquartile range 8.5 to 19.7 per 1,000 live births). Counties with higher NTSV cesarean delivery rates had lower newborn complication rates: unadjusted coefficient -0.31 [95% CI -0.40 to -0.21], adjusted coefficient -0.14 [95% CI -0.23 to -0.04]. When counties with outlying NTSV rates were excluded, the adjusted coefficient for NTSV rate was -0.21 [95% CI -0.32 to -0.10]. Every percentage point increase in county-level NTSV cesarean delivery rates was associated with 0.14 fewer [95% CI 0.4 to 0.23] severe UNC per 1,000 livebirths. The potential neonatal benefits of cesarean delivery should be balanced against the known maternal risks and the less severe but more common newborn complications (e.g., TTN) when setting local and national quality metric targets.
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