Why is the cesarean delivery rate so high in Alabama? An examination of risk factors, 1991-1993

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Factors affecting Taiwanese women's choice of Cesarean section

The rising rate of cesarean section (CS) is a subject of concern, intensive discussion, and investigation. However, few, if any, systematic studies of this trend have been recorded among the oriental populations. This study examines factors that may contribute to the high incidence of CS in Taiwan, where the rate of CS is among the highest in the world. Multiple logistic regression and stratified analyses were used to determine the association between CS and various factors, including provider and patient parameters. Our study sample of 2,497 cases was drawn from a total of 10,654 in-patient deliveries in Chang Gung Memorial Hospital of Taiwan. A number of factors associated with the use of CS were explored, including maternal age, occupation, education and marital status of the mother, sex and body weight of the infant at birth, parity, insurance status, source of admission, and time of birth. Our study also shows that CS in Taiwan is affected by the folk belief of Pe-Ji, which influences the preference of some patients for delivery at a specific time. Such a preference reflects a unique right of choice by women in Taiwan.

Unnecessary cesarean delivery in Louisiana: an analysis of birth certificate data

OBJECTIVE

The purpose of this study was to explore the temporal trends and factors that are associated with cesarean deliveries and potentially unnecessary cesarean deliveries.

STUDY DESIGN

The Louisiana birth certificate database was evaluated to identify a total of 57 potential indications/risk factors and maternal demographic factors that are associated with methods of delivery over the period from January 1993 to December 2000. A cesarean delivery without any potential indications/risk factors in the birth certificate was classified as unnecessary.

RESULTS

The primary cesarean delivery rate decreased and the repeat cesarean delivery rate increased significantly during the study period. But neither the absence nor the presence of potential indications/risk factors accounted for these changes. The average potentially unnecessary primary and repeat cesarean deliveries in Louisiana were 17 and 43, respectively, per 100 cesarean deliveries over the years 1993 through 2000.

CONCLUSION

The proportions of potentially unnecessary cesarean deliveries are relatively high in Louisiana. It is important to explore the influence of nonclinical factors on unnecessary cesarean delivery to reduce the cesarean rates.

Tertiary care improves the chance for vaginal delivery in women with preeclampsia

OBJECTIVE

The purpose of this study was to determine whether the level of hospital care affects cesarean delivery rates for women with preeclampsia.

STUDY DESIGN

We conducted a population-based cohort study using Missouri birth certificate data for 1993 through 1999. Logistic regression was used to analyze data from 13,646 nulliparous women with preeclampsia who were delivered of singleton live births.

RESULTS

After adjustment was made for gestational age and birth weight, the data showed that women with preeclampsia at primary and secondary hospitals were more likely to be delivered by cesarean delivery (odds ratio, 1.37; 95% CI, 1.24,1.51; and odds ratio, 1.16; 95% CI, 1.07,1.26, respectively) than at tertiary hospitals. For women who were delivered at >or=37 weeks of gestation, cesarean delivery rates were 38.0%, 33.7%, and 30.0% for primary, secondary, and tertiary hospitals, respectively. Dysfunctional labor, cephalopelvic disproportion, and fetal distress were more commonly noted at primary and secondary hospitals (P<.001).

CONCLUSION

Levels of expertise and staffing at tertiary hospitals may allow greater attempts and success with vaginal delivery among women with preeclampsia compared with primary or secondary hospitals.

Comparing physician and administrator responses to cesarean section guidelines and actual practice

BACKGROUND

A cross-sectional study was conducted in 1996 to determine to what extent hospitals have adopted guidelines to improve the appropriate use of cesarean section (C-section); discover attitudes of obstetricians toward C-section guidelines; and explore how physician attitudes toward guidelines interact with organizational features.

METHODS

The study consisted of two components: (1) Telephone interviews with hospital administrators from Michigan hospitals providing obstetric care (response rate: 100%); these interviews were intended to determine whether guidelines were in use and the processes for their development and implementation. (2) A self-administered mail survey assessing the attitudes of 266 Michigan obstetricians (response rate: 57%), intended to assess their attitudes toward the content and effects of C-section guidelines.

RESULTS

Twenty-nine percent of hospitals were using C-section guidelines, according to reports from hospital administrators. Mean C-section rates were not significantly different between hospitals using guidelines and those not using guidelines (23.2% and 22.4%, p = 0.49). More than 80% of physicians felt that the guidelines were supported by the literature and were applicable in daily practice, and agreed with their ideas about C-section performance, and 67% reported that guidelines would have no or minimal effect on their practice. However, only 55% of physicians and administrators agreed on the presence or absence of guidelines at their hospital (kappa = 0.09).

DISCUSSION

Physicians appear to agree with guidelines and believe they are already following them, despite high C-section rates. Physicians' attitudes toward guidelines are not necessarily a reflection of actual practice. If C-section guidelines are to decrease excessive C-section rates, stronger, more integrated implementation strategies are needed.

The epidemiology of labor induction: Arizona, 1997

OBJECTIVE

This study was undertaken to describe labor induction risk factors and consequences among women with term singleton gestations with vertex presentation.

STUDY DESIGN

Arizona births in 1997 (N = 65,607) were studied by means of stratified analysis and logistic regression.

RESULTS

Labor induction occurred in 20.3% (n = 13,288). Labor induction risk factors were as follows: race or ethnicity (white non-Hispanic 25.3%; Hispanic, 13.9%; foreign-born Hispanic, 10.3%; and US-born Hispanic, 18.5%), education (<12 years, 14.1%; >12 years, 24.6%), payor (private insurance, 24.5%; Medicaid, 16.7%), hospital type (government controlled, 13.7%; investor owned, 30.5%). Race or ethnicity and hospital type remained important determinants of labor induction in the multivariate analysis. Relative risks of cesarean delivery with labor induction were as follows: nulliparous, 1.38; parous with no previous cesarean delivery, 1.00; and parous with previous cesarean delivery, 0.50.

CONCLUSION

Large variations in labor induction were noted across maternal ethnicity and hospital type categories. Labor induction increased cesarean delivery rates among nulliparous women, whereas no increase was seen among parous women with no previous cesarean delivery. Labor induction was used less often among those with previous cesarean delivery; when it was used in this group, however, it was associated with a lower cesarean delivery rate.

Variations in risk-adjusted cesarean delivery rates according to race and health insurance

OBJECTIVE

To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.

DESIGN

Retrospective cohort study in 21 hospitals in northeast Ohio.

SUBJECTS

25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995.

METHODS

Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis.

MAIN OUTCOME MEASURES

Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance.

RESULTS

The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant.

CONCLUSION

After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.

Maternal fatigue: implications of second stage labor nursing care

The parameters of fatigue have been studied in recent years in relation to women's health and the childbearing period. Less research emphasis has been placed on second stage labor, a period of time that can encompass considerable physiologic and psychologic fatigue. Consideration to minimizing second stage labor fatigue by altering conventional support practices is needed. This includes minimizing long periods of strong pushing or bearing down efforts in conjunction with sustained breath holding, particularly for women receiving epidural anesthesia. The potential sequelae of second stage labor fatigue, recommendations for practice changes, and new research directions are discussed.

Estimating the proportion of unnecessary Cesarean sections in Ohio using birth certificate data

The main objective of the study is to present a method that estimates the proportion of unnecessary Cesarean sections (C-sections) using birth certificate data. This population-based cross-sectional study uses two major databases--Ohio birth certificates and Medicaid eligibility files--and includes singleton infants born during the period July 1991 through June 1993 (n = 262,013). A total of 57 variables indicative of adverse events, including maternal medical risk factors, complications of labor and delivery, and congenital anomalies that are available on the birth certificate, are examined to estimate the rate of unnecessary C-sections. The results obtained through this method indicate that nearly 40% of the repeat C-sections had no documented abnormalities on the birth certificate to justify a C-section. Because studies using medical records have yielded similar results, we believe that using birth certificate data may be a reliable method to measure and monitor the rate of unnecessary C-sections.