Vast variation in cesarean rates across the United States

Even after stratification by hospital size, teaching status, and geographic location, rates of cesarean delivery among hospitals across the United States vary almost 10-fold-from a low of 7.1% to a high of 69.96%. Those are the surprising findings of a study, performed by researchers from the University of Minnesota and the University of British Columbia, which appeared in the March 2013 issue of Health Affairs. 

Notably, in addition to the 10-fold variation in total cesarean rates among US hospitals, the data revealed a 15-fold variation (from 2.4% to 36.5%) in cesarean deliveries in low-risk pregnancies. The researchers note that they had expected a more limited variation in the low-risk population.

The researchers examined data from 817,318 deliveries that occurred in 2009 at 593 different hospitals. Small and rural hospitals showed slightly more variability in cesarean rates, whereas variability was lower among teaching hospitals. 

High cesarean rates have been of concern to ob/gyns for decades and there have been many calls to reduce the number of such deliveries in the United States. Despite this, according to the study authors, cesareans have increased from 20.7% of all deliveries in 1996 to 32.8% in 2011. In international comparisons, US cesarean rates exceed those for similar countries, and without measurable clinical benefit.

Cesarean delivery is much more costly than vaginal delivery ($12,739 vs $9,048 for private health insurers in 2010, according to this study). 

The researchers also note that cesarean delivery is “an important, potentially lifesaving intervention” and that the number of clinical indications for a cesarean has increased in recent years. However, they say that these changes alone cannot explain the rising rates of cesarean delivery. They postulate that instead, practice patterns are a likely driver of variations in delivery mode.

In a lengthy discussion, the researchers comment on 4 “promising directions” for reducing variations in cesarean rates across hospitals: 

1. improving specialization and triage for maternity care;

2. collecting and measuring data on maternity care quality;

3. using Medicaid policy to improve hospital management practices in labor and delivery units; and

4. enhancing patient-centered decision making for maternity care through public reporting.

Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff. 2013;32(3):527-535.