Abstract
Objectives Cesarean rates vary widely across the U.S. states; however, little is known about
the causes and implications associated with these variations. The objectives of this
study were to quantify the contribution of the clinical and nonclinical factors in
explaining the difference in cesarean rates across states and to investigate the associated
health outcome of cesarean variations.
Study Design Using the Hospital Cost and Utilization Project State Inpatient Databases, this retrospective
study included all nonfederal hospital births from Wisconsin, Florida, and New York.
A nonlinear extension of the Oaxaca–Blinder method was used to decompose the contributions
of differences in characteristics to cesarean variations between these states. The
risk factors for cesarean delivery were identified using separate multivariable logistic
regression analysis for each State.
Results The difference in clinical and nonclinical factors explained a substantial (~46.57–65.45%)
proportion of cesarean variations between U.S. states. The major contributors of variation
were patient demographics, previous cesareans, hospital markup ratios, and social
determinants of health. Cesarean delivery was significantly associated with higher
postpartum readmissions and unplanned emergency department visits, greater lengths
of stay, and hospital costs across all states.
Conclusion Although a proportion of variations in cesarean rates can be explained by the differences
in risk factors, the remaining unexplained variations suggest differences in practice
patterns and imply potential quality concerns. Since nonclinical factors are likely
to play an important role in cesarean variation, we recommend targeted initiatives
increasing access to maternal care and improving maternal health literacy.
Key Points
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Cesarean rates vary widely almost two folds within U.S. states.
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The difference in risk factors explained substantial (~46.57–65.45%) of the cesarean
variations.
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Mother race, hospital factors, and social determinants comprised major proportion
of explained variation.
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Adverse outcomes and increased expenditures were associated with cesarean than vaginal
delivery.
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Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries
are reduced.
Keywords
pregnancy - cesarean section - maternal health - Medicaid - readmission
