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Am J Perinatol 2023; 40(13): 1473-1483
DOI: 10.1055/s-0041-1736538
Original Manuscript

A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States

Autoren

  • Hasan Symum

    1   Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida

  • José L. Zayas-Castro

    1   Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
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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

  • Cesarean rates vary widely almost two folds within U.S. states.

  • The difference in risk factors explained substantial (~46.57–65.45%) of the cesarean variations.

  • Mother race, hospital factors, and social determinants comprised major proportion of explained variation.

  • Adverse outcomes and increased expenditures were associated with cesarean than vaginal delivery.

  • Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries are reduced.

Keywords

pregnancy - cesarean section - maternal health - Medicaid - readmission

Supplementary Material



Publikationsverlauf

Eingereicht: 21. August 2021

Angenommen: 13. September 2021

Artikel online veröffentlicht:
19. Oktober 2021

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