Michael R . Law , and Beth A . Virnig Cesarean Delivery Rates Vary Tenfold Among US Hospitals ; Reducing Variation

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting. C esarean delivery is the most common operating room procedure performed among all patients in US hospitals, and its use is growing. Cesarean rates increased from 20.7 percent of all deliveries in 1996 to 32.8 percent in 2011. In international comparisons, US cesarean rates exceed those for similar countries, without measurable clinical benefit. The rise in the cesarean rate is commonly attributed to several factors, including a higher rate of conditions that may necessitate cesarean delivery—such as multiple gestation, maternal obesity, preterm labor, gestational diabetes, or hypertension—as well as physicians’ concerns about liability and malpractice. But evidence indicates that these factors do not fully account for the wide differences in cesarean rates observed across states and countries. Cesarean delivery is an important, potentially lifesaving intervention. Although common, cesarean delivery is major abdominal surgery that carries distinct risks compared with vaginal delivery: greater chance of infection, injury, blood clots, and need for emergency hysterectomy. It also can cause persistent pain, compromise the establishment of breast-feeding, and complicate later deliveries. Cesarean delivery is often performed to improve neonatal outcomes and mitigate risk; however, it is associatedwith a greater risk of asphyxia, respiratory distress, and other pulmonary disorders in infants. The widespread use of cesarean delivery has important policy implications. Cesareandelivery is much more costly than vaginal delivery ($12,739 versus $9,048 for private health insurers in 2010). Adverse outcomes and complications have substantial cost implications for delivery systems and health insurers, both public and private. This fact is particularly salient for maternal and neonatal health interventions, as hospital charges for these services exceed those for any other condition. The state and federal budget impacts are particularly notable, as public doi: 10.1377/hlthaff.2012.1030