Variation in the Rates of Operative Delivery in the United States

Hospital Corporation of America, Division of Perinatal Safety, Nashville, TN, USA.
American journal of obstetrics and gynecology (Impact Factor: 4.7). 07/2007; 196(6):526.e1-5. DOI: 10.1016/j.ajog.2007.01.024
Source: PubMed


This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making.
We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004.
In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery.
Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

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    • "Infants delivered by cesarean section are well known to have an increased risk of disturbed postnatal adaptation [3-5]. Despite of an increasing number of deliveries by c-section [6,7], only limited data are available regarding medical care in these infants. However, for subsequent evidence based guidelines regarding medical support of postnatal transition more research on that issue is required. "
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    ABSTRACT: Background Whereas good data are available on the resuscitation of infants, little is known regarding support of postnatal transition in low-risk term infants after c-section. The present study was performed to describe current delivery room (DR) management of term infants born by c-section in our institution by analyzing videos that were recorded within a quality assurance program. Methods DR- management is routinely recorded within a quality assurance program. Cross-sectional study of videos of term infants born by c-section. Videos were analyzed with respect to time point, duration and number of all medical interventions. Study period was between January and December 2012. Results 186 videos were analyzed. The majority of infants (73%) were without support of postnatal transition. In infants with support of transition, majority of infants received respiratory support, starting in median after 3.4 minutes (range 0.4-14.2) and lasting for 8.8 (1.5-28.5) minutes. Only 33% of infants with support had to be admitted to the NICU, the remaining infants were returned to the mother after a median of 13.5 (8-42) minutes. A great inter- and intra-individual variation with respect to the sequence of interventions was found. Conclusions The study provides data for an internal quality improvement program and supports the benefit of using routine video recording of DR-management. Furthermore, data can be used for benchmarking with current practice in other centers.
    Full-text · Article · Jul 2014 · BMC Pregnancy and Childbirth
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    • "We consider that all trainees should be proficient in the use of forceps, and obstetric training that prioritizes the use of the ventouse may be contributing to the rising rate of cesarean delivery. As recently highlighted, the wide variation observed in OVD would not be considered safe if it were a parameter in the airline industry [1]. The application of quality control tables to analyze rates can be used to identify maternity services that are statistical outliers, and thus identify obstetricians who may benefit from supplementary training in OVD [25]. "
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    ABSTRACT: Objective To compare the percentage of operative vaginal delivery (OVD) among all publicly funded maternity hospitals in Ireland and to develop quality control performance tables to facilitate national benchmarking. Methods The analysis included deliveries of neonates weighing 500 g or more in publicly funded hospitals in Ireland in 2010. Information was obtained from the Irish National Perinatal Reporting System. Maternities delivering in 1 private hospital or at home, and those with unknown parity were excluded. Mean ± SD OVD rates were calculated per hospital. Quality control tables were devised. Results In 2010, there were 75 600 deliveries, of which 73 029 met the inclusion criteria. The number of deliveries per hospital ranged from 1284 to 9759. The OVD rate per hospital was 15.3 ± 2.6% (range, 11.7–20.4%). The OVD rate was 29.1% among primigravidas (n = 30 468) compared with 6.7% among multigravidas (n = 42 561) (P < 0.001). Using quality control tables, 52.6% (n = 10) and 31.6% (n = 6) of hospitals were more than 1 SD outside the national mean for forceps and ventouse delivery, respectively. Conclusion Wide variations were found in both the range of OVD and instrument choice among maternity hospitals in Ireland, raising questions about practice and training in contemporary obstetrics.
    Full-text · Article · Jun 2014 · International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
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    • "However, the reported effect of race/ethnicity on primary cesarean rates is inconsistent among groups and between studies, possibly reflecting study design diversity, variation in the distributions of racial/ethnic groups’ prevalent in different geographic areas, and unreliable race/ethnicity measures. Furthermore, due to considerable intra-regional variation, [10,13], national data on primary CDs may not reflect local trends, substantiating the need to monitor rates at the individual hospital level [14]. Therefore, this study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity at a single tertiary-care academic center with a diverse urban and suburban population. "
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    ABSTRACT: Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three is now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center. A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006--2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups. The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor. Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.
    Full-text · Article · Sep 2013 · BMC Pregnancy and Childbirth
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