Abstract
ObjectiveWe examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics.MethodsBirth certificate and maternal in-patient hospital discharge records for 2004–06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean deliveryResultsOverall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023).ConclusionEven after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate.
Highlights
Cesarean deliveries have been increasing steadily since 1997 in Massachusetts, mirroring the United States (US) trends [1,2]
Using a population-based dataset that links birth certificates to hospital discharge data for all births in Massachusetts, we investigate whether hospital variation in cesarean deliveries among a low risk population can be explained by the socio-demographic, pregnancy, and clinical characteristics of mothers
Maternal socio-demographics, and time of birth were ascertained from the Birth Certificates (BC), while method of delivery, infant birth weight, gestational age, induction of labor, parity, plurality, nonvertex/malpresentation, and preexisting medical conditions were ascertained from the linked BC and Hospital Discharge (HD) data (Tables S1, S2)
Summary
Cesarean deliveries have been increasing steadily since 1997 in Massachusetts, mirroring the United States (US) trends [1,2]. Cesarean delivery rates vary widely across states and appear to differ across hospitals. While such differences could reflect differences in the characteristics of hospitals [6,7], they could be reflective of differential concentration of maternal characteristics strongly associated with having a cesarean birth across hospitals. Ascertaining whether socio-demographic, pregnancy, and clinical characteristics of mothers explain hospital differences in the likelihood of having a cesarean delivery is critical in understanding the specific role of hospitals in contributing to this observed variation. Using a population-based dataset that links birth certificates to hospital discharge data for all births in Massachusetts, we investigate whether hospital variation in cesarean deliveries among a low risk population can be explained by the socio-demographic, pregnancy, and clinical characteristics of mothers
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