Assessing low-risk cesarean delivery rates: Florida's 4-year study insights


A comprehensive study reveals variations in monitoring low-risk cesarean delivery rates across 5 metrics, emphasizing the significance of timely and accurate assessment from birth certificate data.

Assessing low-risk cesarean delivery rates: Florida's 4-year study insights | Image Credit: © samrith - © samrith -

Assessing low-risk cesarean delivery rates: Florida's 4-year study insights | Image Credit: © samrith - © samrith -

Quality monitoring of low-risk cesarean delivery rates is associated with accurate and timely assessment, according to a recent study published in the American Journal of Obstetrics & Gynecology.


  1. Cesarean delivery rates in Florida in 2020 were 35.9%, highlighting its prevalence and potential associated risks for maternal and neonatal complications.
  2. Nulliparous deliveries are common and often involve complicated and prolonged labor, increasing the chances of nonmedically indicated cesarean deliveries. Thus, interventions targeting nulliparous women could be particularly impactful.
  3. Various metrics, such as the NTSV metric, the Joint Commission (JC) metric, and the Society for Maternal-Fetal Medicine (SMFM) metric, are employed to monitor low-risk cesarean delivery rates. However, the study emphasizes that cesarean delivery rates based on birth certificate (BC) data are more accurate and timely than those derived from other sources.
  4. The 4-year study analyzed data from 733,307 live births across 103 maternity hospitals in Florida. There was variation in low-risk cesarean delivery rates among hospitals, with rates ranging from 19.3% to 60.6% based on the NTSV-BC metric.
  5. The study underscores the importance of clarity regarding the definition of "low risk" when discussing cesarean delivery rates. The findings suggest that BC data offers a more accurate reflection of low-risk cesarean delivery rates compared to other data sources.

Cesarean delivery, which has been linked to increased risks of maternal and neonatal morbidities and mortalities, had a rate of 35.9 in Florida in 2020. Women are more likely to have the same delivery in subsequent births, making strategies focusing on nulliparous women more likely to be effective.

Nulliparous deliveries account for 45% of deliveries in California, indicating they are a common method of birth. However, nulliparous deliveries are associated with complicated and longer labor, increasing the risk of nonmedically indicated cesarean delivery.

Common measures for monitoring low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex (NTSV) metric, the Joint Commission (JC) metric, and the Society for Maternal-Fetal Medicine (SMFM) metric. However, there is little data comparing the accuracy of these methods.

To evaluate hospital rate differences in Florida across 5 metrics of low-risk cesarean delivery rates based on risk methodology, metric type, and data source, investigators conducted a 4-year study. Data sources evaluated included the Florida Department of Health and Agency for Health Care Administration.

Florida birthing hospitals with at least 1000 live births during the study period were included in the analysis. Patient exclusion criteria included missing or invalid social security numbers in nonfederal maternity hospitals.

The first metric only used birth certificate (BC) data, with classification based on NTSV designation. The second and third metrics used all available data elements in the linked dataset, using a condition list recommended by JC and SMFM, respectively. The fourth and fifth metrics were nearly identical to the second and third, but only used hospital discharge (HD) data.

Cesarean delivery was determined by a birth route variable recorded as cesarean on a BC, a maternal diagnosis code on the delivery hospitalization starting with O82, a procedure code beginning with 10D00Z0, 10D00Z1, or 10D00Z2, or an infant Z3801 diagnosis code for birth hospitalization.

There were 733,307 live births across 103 maternity hospitals between January 1, 2016, and December 31, 2019, included in the analysis. Most births were full-term, and 43.4% of mothers were non-Hispanic White, 57.1% had some college or more education, 49% were on Medicaid, 59.9% were multiparous, and 40.8% were healthy weight.

Hypertension was reported in 14.2% of mothers and diabetes mellitus in 8%. Approximately one-third of live births were comprised of low-risk births when using BC data, but this rate increased to approximately two-thirds when using HD data.

The median number of low-risk births decreased across linked metrics, at 1925 for NTSV-BC, 1826 for JC linked, and 1813 for SMFM linked. This trend was also observed across HD metrics, at 3968 for JC-HD and 3864 for SMFM-HD. The decrease was more significant when using HD data only.

In the NTSV-BC metric, rates of cesarean delivery within hospitals ranged from 19.3% to 60.6%. The highest low-risk cesarean delivery rate was seen in the NTSV-BC measure and the lowest in the SMFM-HD measure.

These results indicated low-risk cesarean delivery rates from BCs are timelier and more accurate than those from other data sources. Investigators concluded researchers and clinicians should be clear on which definition of low risk is being referred to.


Obure R, Reid CN, Salemi JL, et al. Assessing hospital differences in low-risk cesarean delivery metrics in Florida. Am J Obstet Gynecol. 2023;229:684.e1-9. doi:10.1016/j.ajog.2023.06.016

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