AHRQ Stats: Cesarean Births
About 35 percent of cesarean sections, or C-sections, were performed for low-risk deliveries in 2013. Low-risk C-section rates varied tenfold (from 4.6 to 46.9 per 100 low-risk deliveries) among the largest hospitals that account for 80 percent of all births, and there was even wider variation among smaller hospitals. (Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project Statistical Brief #211, Variation in the Rate of Cesarean Section Across U.S. Hospitals, 2013.)
Kamila Mistry, Ph.D., M.P.H., Kathryn R. Fingar, Ph.D., M.P.H., and Anne Elixhauser, Ph.D.
Although the overall cesarean section (C-section) rate in the United States has declined slightly in recent years, nearly a third of all births continue to be delivered by C-section1—higher than in many other industrialized countries.2 A number of factors may contribute to high C-section rates, including medical conditions and complications that may necessitate the procedure, such as multiple gestations, older maternal age due to delayed childbearing, preterm labor, obesity, gestational diabetes, and hypertension.3 Other factors unrelated to medical indication may also influence the decision to perform a C-section, including hospital policies regarding elective deliveries and patient preference, as well as physician concerns regarding liability related to a poor obstetrical outcome.4,5,6
C-section is the most common surgical procedure performed in the United States.7 This operation carries additional risks compared with vaginal delivery, such as infection and postoperative pain.8,9 A C-section also may make it more difficult for the mother to establish breastfeeding and may complicate subsequent pregnancies.10,11 Given potential risks and associated costs—in 2011, the average cost of a hospital stay resulting in C-section was over 50 percent higher than a stay involving vaginal delivery12—reducing the C-section delivery rate continues to be an important focus of public health efforts nationwide, particularly for low-risk deliveries with no medical indication for the procedure.13
Consensus guidelines from the American Congress of Obstetricians and Gynecologists and other national efforts to improve perinatal care have shown promise in reducing nonmedically indicated C-sections.14 However, recent research has found wide variation in hospital C-section rates even for low-risk deliveries.15 This variation raises questions about the quality of maternal care and has important implications for maternal and neonatal outcomes and costs for hospitals, delivery systems, and insurers.
This Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents information on variation in the rate of total and low-risk C-sections across U.S. hospitals in 2013. It expands on previous studies in two significant ways—by using the State Inpatient Databases (SID) rather than the Nationwide Inpatient Sample (NIS) and by using a new definition of low-risk C-section developed by the Society of Maternal-Fetal Medicine in 2016, which is more clinically comprehensive than other prior definitions available from the Joint Commission and Agency for Healthcare Research and Quality.16 The SID are used because they contain data on a census, or near census, of hospitals in each State and include all discharges from each hospital, making it possible to generate accurate hospital-level statistics. Numbers presented here are not national estimates, but rather actual counts from all States included.
This Statistical Brief builds on prior work that examined variations in C-sections by hospital bed size, teaching status, and geographic location using the NIS, from which 593 hospitals were used for analysis.17 In comparison, this Statistical Brief includes data from virtually all hospitals across 43 states and the District of Columbia—2,719 community, nonrehabilitation hospitals in total—accounting for about 95 percent of the U.S. population and deliveries nationwide. Although prior research excluded hospitals with fewer than 100 deliveries in order to ensure that the C-section rate across the sample was sufficiently stable,18 this analysis draws on data from all hospitals except those with 1-9 deliveries (n=51 hospitals) to allow for the inclusion of small hospitals with lower delivery volumes. Deliveries relate to the stay of the mother rather than the newborn.
This Statistical Brief presents the rate of C-section per 100 total and low-risk deliveries among women aged 15-44 years. Variation in C-section rates is assessed by examining the distribution of C-section rates across hospitals. Data are presented on minimum and maximum values (i.e., outliers) and the mean C-section rate according to hospital delivery volume. The mean C-section rate is also examined by additional hospital characteristics. Differences of 10 percent or greater are noted in the text.