Analysis of the Wide Variation In Cesarean Birth Rates in US Hospitals: Another Call for Childbirth Education

Implied.  Under the radar.  Hinted at.  All of these can be used to describe the latest in a flurry of articles suggesting that childbirth education be ramped up and that evidence-based information be more readily available to pregnant women.

For example:

In the United States, childbirth is the most common reason for hospitalization…and it often brings in a substantial portion of revenue for the hospital.  With the current US cesarean rate wavering at 32.8%, it is any wonder that an examination of the drastic variation in rates among hospitals has been launched.

In a recent article published in HealthAffairs, authors Katy Backes Kozhimannil, Michael Law and Beth Virnig worked with data from 2009 and examined 593 US hospitals.   They found that cesarean birth rates varied tenfold across hospitals – from 7.1% to 69.9%. 

Cesarean delivery is an important, potentially lifesaving, medical procedure and some variance in hospital rates would be expected based on differences in patient characteristics. In order to address this, researchers also examined cesarean rates among a subgroup of lower-risk patients: mothers whose pregnancies were not preterm, breech, or multiple gestation and who had no history of cesarean delivery.

Among this group of women with lower-risk pregnancies, in which more limited variation might be expected, hospital cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent.
"We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status," said lead author Katy B. Kozhimannil, Ph.D., assistant professor in the University of Minnesota School of Public Health. "The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians, hospitals and policymakers."

Kozhimannil and her colleagues suggested recommended four major policies to reduce variations:

First, women need to be offered the right care for their own pregnancies. Evidence from earlier studies shows women with healthy pregnancies benefit from care provided by midwives, support from trained doulas, and access to care in licensed birth centers. Women with low-risk pregnancies should have access to care options that may benefit them, with strong referral systems and specialized care for complications that may arise.

More and better data on the quality of maternity care are needed to support the rapidly advancing clinical evidence base in obstetrics. Clinicians and hospitals cannot improve maternity care, and insurers cannot pay for such improvements, without clear and consistent measures of quality.
Tying Medicaid payment policies to quality improvement programs may influence hospital policies and practices and provide incentives and reward hospitals and clinicians for providing consistent, evidence-based care.

Finally, information about cesarean rates and maternity care should be more readily available to pregnant women, who have time, motivation, and interest to research their options. However, they lack access to unbiased, publicly-reported information about cesarean delivery rates and other aspects of maternity care.

Yet, another clear mandate for the need for childbirth education.  

And not childbirth education in the form of regurgitated hospital expectations and current policy…”unbiased, publicly-reported information about cesarean delivery rates and other aspects of maternity care.”

Kozhimannil et al. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues.  Health Affairs March 2013, Vol. 32, No. 3.