Sunday, November 2, 2014

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

Photo courtesy "Angela"
There's a new study out that discusses the variation in cesarean rates between hospitals in the United States.

Practice variation is a serious problem in obstetrics. Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population.

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn't explain the wide variation in rates between many hospitals.

For example, in the study above, the mother's risk status and diagnoses did not explain the variation in cesarean rates between hospitals:
We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”
There were several key points highlighted in the article about the study, including:
  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.
This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother's risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates?

This study is not the first to show that the culture of a hospital, their policies, and their routine practices all help determine how likely a woman is to "need" a cesarean in that hospital.

This is important because while cesareans can be life-saving at times, they present more risk for infection, bleeding, pain, neonatal breathing problems, and complications in future pregnancies. It matters where and with whom a woman gives birth.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use

One leading consumer education site points out, "Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate."

Yet it is not always easy to find out the cesarean rates* of local hospitals in some states, and many hospitals remain largely unaccountable for sky-high cesarean rates, although we are beginning to see marginal progress in some places towards accountability. But even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals. How is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states: 
Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth...and these results indicate that we have a long way to go toward reaching this goal in the U.S.

**An additional suggestion: Researchers should start examining cesarean practice variations in obese patients too. Research strongly suggests there are major practice variations in cesarean utilization for "obese" mothers between hospitals, yet this is a topic that is rarely broached in research. More exploration of this dichotomy might help reduce the cesarean rate in this group.

***Post received minor reference and picture edits on 11/6/14.


*See for hospital level cesarean rates in most U.S. states. Consumer Reports also has a recent article with some hospital-level c-section rates in the U.S.

PLoS Med. 2014 Oct 21;11(10):e1001745. doi: 10.1371/journal.pmed.1001745. eCollection 2014. Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database. Kozhimannil KB1, Arcaya MC2, Subramanian SV2. PMID: 25333943
BACKGROUND: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. METHODS AND FINDINGS: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project-a 20% sample of US hospitals-we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. CONCLUSIONS: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture-in determining cesarean section use.
Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL1, Belfort MA, Hankins GD, Meyers JA, Houser FM. PMID: 17547880
OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.
Neonatology. 2014 Oct 4;107(1):8-13. [Epub ahead of print] Women Are Designed to Deliver Vaginally and Not by Cesarean Section: An Obstetrician's View. Visser GH. PMID: 25301178
Worldwide, there is a rapid increase in deliveries by cesarean section. The large differences among countries, from about 16% to more than 60%, suggest that the cesarean delivery (CD) rate has little to do with evidence-based medicine. In this review, the background for the increasing CD rate is discussed as well as the limited positive effects on neonatal outcome in both term and preterm neonates. Negative effects of CD, including direct maternal morbidity, complications of subsequent pregnancies and iatrogenic early delivery resulting in increased neonatal morbidity, are discussed in addition to long-term implications for the offspring involving altered development of the immune system. The 'battle' to lower the CD rate will be difficult, but we should not forget that women are designed to deliver vaginally and not by cesarean section. 


crystal_b said...

I'm in Missouri, where we don't have hospital-level data (even though it's the "show-me state"!) I wrote to a person in the dept of health asking about it and was fed the "serving different populations" BS.

Well-Rounded Mama said...

Keep pressing, Crystal. If there's enough consumer pressure, the state may change its policy.

One local state used to publish its cesarean rates, then stopped for a while. It took us some pressure for a while, but they did start publishing it again eventually.

There is a very strong push towards more transparency and at least some accountability in healthcare these days, so it will get harder and harder for states like MO and SC and places like D.C. to withhold these. Keep the pressure on, and use publicity to help you.

Your best publicity angle may be the "Show Me State" angle. :-)

Mich said...

I'm not sure if you've shown Canadian c-rates, but I'd be interested to know if the 35% avg. rate is matched in Canada. And also to know which hospital has the highest vs. the lowest.

Well-Rounded Mama said...

A quick google found these links you can dig around in for more information: