Cesarean Section Rates: Teaching vs' NonTeaching Hospitals

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Cesarean Section Rates Teaching vs. Non-Teaching
Hospitals

• Mary Rimsza, MD, Kathy Bailey, LMSW, David
  Becerra, MSW, Blythe Fitzharris, LCSW, Maria
  Gurrola, MSW, Monica Parsai, MSW, Kathlyn Shahan,
  MSW
• Arizona State University
• Center for Health Information and Research
• School of Computing and Informatics
• Ira J Fulton School of Engineering
• 12th Annual Maternal and Child Health
  Epidemiology Conference
• December 6-8, 2006
• Atlanta, Georgia

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Cesarean Sections

• Definitions
• Cesarean section (C-section)- the delivery of the
  newborn through an incision in the mothers
  abdominal wall and uterus.
• Primary cesarean section (PCS)- the first birth
  by cesarean section.
• Secondary cesarean section-repeat C-section

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Cesarean Sections in the United States

• Healthy People 2000 and Healthy People 2010
  called for a reduction in the overall cesarean
  rate to 15 and a repeat cesarean rate of 63.
• The World Health Organization stated that no
  region in the world is justified in having a rate
  of cesarean births over 15.
• Despite this, rates of cesarean sections in the
  United States continue to rise.

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Cesarean Sections in the United States

• In 2002, almost a quarter of all first time
  mothers delivered by cesarean section.
• In 2004, the number of cesarean sections
  increased by 6 and was 29.1 of all births in
  the U.S.

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Concerns Regarding Overuse of Cesarean Sections

• A growing number of C-sections are not due to
  medical necessity.
• Problems that may arise with C-sections
• Infections
• Hemorrhage
• Embolism
• Anesthesia complications
• Prolonged recovery period for mother
• Risk of uterine rupture in subsequent pregnancies

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Factors That May Influence Use of Cesarean
Sections

• For the physician
• May decrease medical liability risk
• Convenience of scheduled delivery
• Increased reimbursement for C-sections
• Patient preference for C-section
• Eliminates need to monitor laboring patients
• For women
• Age older women more likely to fail to
  progress in labor
• Previous C-section
• Small pelvis
• Multiple births
• Breech position

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Cesarean Sections for Ethnic Minority Women

• Women of color are more likely to be poor or
  uninsured.
• Previous studies have found that being
  African-American was strongly associated with a
  higher likelihood of cesarean delivery.
• Native American women have the lowest rates of
  PCS when compared to all other ethnicities.
• In county hospitals, Latinas and
  African-Americans were more likely to have
  cesarean delivery than Whites.

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Research Question

• Does ethnicity, insurance status, and type of
  hospital affect the use of primary cesarean
  sections in Maricopa County, Arizona?

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Sample

• Data
• Arizona HealthQuery (AZHQ) houses health care
  information voluntarily provided by hospitals,
  health care systems, insurers, physician groups,
  community health centers, and other ambulatory
  care centers.
• The AZHQ data used for this study was from
  January 1, 2004 to December 31, 2004.
• The data consists of all records for hospitals
  that provided obstetric services with at least
  100 births within a year.
• 28 hospitals in Maricopa County, Arizona were
  included in the data set.
• 3 hospitals were classified as teaching hospitals
• 25 hospitals were classified as non-teaching
  hospitals.
• The total sample, excluding the missing data
  (766) was 56,520.

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Demographics

• Non-Teaching Hospitals
• 38,578 total births
• 4,591 primary cesarean sections
• Teaching Hospitals
• 17,942 total births
• 1,579 primary cesarean births

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• Results

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Table I Descriptive statistics and correlations
with PCS
Correlation is significant at the 0.01 level
(2-tailed).
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Likelihood of Primary Cesarean Section
Logistic Regression
plt .05 plt.01 plt.001 Reference Groups
AHCCCS Insurance, Whites, Non-Teaching Hospital
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Results

• Uninsured women were less likely than all other
  insurance types to have a cesarean delivery.
• Native American women were less likely to have a
  cesarean section than White women.

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Results

• Women were more likely to have a cesarean section
  if they deliver in non-teaching hospitals.
• Women insured by Medicaid were more likely to
  have a cesarean delivery than women on private
  insurance.
• Women insured by Medicaid are more likely to have
  a cesarean delivery in both teaching and
  non-teaching hospitals.

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Implications

• Ethnicity and insurance status are factors
  associated with the likelihood of cesarean
  deliveries.
• Since minority women are more often poor and
  uninsured than White women, minority women are at
  higher risk of C-section due to lack of
  utilization of medical services and access to
  certain procedures.

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Recommendations

• Ensure public health plans focus on prevention-
  prenatal care to ensure medical complications and
  method of delivery are clearly documented and
  explained to the patient for self-advocacy.
• Ensure the information given to women regarding
  medical procedures is culturally competent and in
  a language the mother can understand.
• Ensure public health plans have standards of care
  as well as the selection and exposure to the
  delivering physician similar to private
  insurance.
• Ensure medical care is based on medical need
  regardless of insurance status.

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Recommendations

• Women should be educated about the increased
  risks associated with C-sections
• Insurers should consider decreasing reimbursement
  for c-section deliveries and increasing
  reimbursement for vaginal deliveries to decrease
  financial incentives. 
• Malpractice reform to decrease physician
  perceived need to do c-section to minimize
  litigation.