Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. Methods and Findings: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. Conclusions: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors' Summar

Rural–Urban Differences in Risk Factors for Motor Vehicle Fatalities

Purpose: To examine rural–urban differences in motor vehicle fatality (MVF) risk factors. Methods: We used 2017 County Health Rankings data to run stratified regression models to estimate county-level correlates of motor vehicle fatalities (MVFs) by rural and urban location. Results: Rural counties have higher rates of MVFs than urban counties (22 vs. 14 per 100,000, p<0.001). Physical inactivity and uninsurance were associated with higher rates of MVFs, as was having a more racially or ethnically concentrated population and larger percentages of younger or older adults. Conclusion: Interventions to reduce MVFs should take geographic location and population composition into account

Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis.

Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status.More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52-0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with >30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47-0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81-8.94; and AOR = 2.68; 95% CI, 1.70-4.23, respectively).Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants

Funnel plots of hospital cesarean rates, overall and for subgroups of women.

<p>Funnel plots show how each individual institution (blue dot) performs compared to the mean (red) and control limits (the 99% prediction interval around the calculated mean). The upper control limit is shown as purple and the lower control limit is shown as green. Cesarean rates for (A) all women, (B) women with no prior cesarean, (C) lower risk women, and (D) higher risk women.</p

Parameter estimates from multilevel models of the association between patient and hospital covariates with odds of cesarean delivery for risk-based subgroups of women.

<p>Models also control for state fixed effects. Bayesian one-tailed <i>p</i>-values based on posterior distributions.</p><p>*<i>p</i><0.05,</p><p>**<i>p</i><0.01,</p><p>***<i>p</i><0.001.</p><p>OR, odds ratio.</p><p>Parameter estimates from multilevel models of the association between patient and hospital covariates with odds of cesarean delivery for risk-based subgroups of women.</p

Parameter estimates from multilevel models of the association between patient and hospital covariates with odds of cesarean delivery, overall and among women with no prior cesareans.

<p>Models also control for state fixed effects. Bayesian one-tailed <i>p</i>-values based on posterior distributions.</p><p>*<i>p</i><0.05,</p><p>**<i>p</i><0.01,</p><p>***<i>p</i><0.001.</p><p>OR, odds ratio.</p><p>Parameter estimates from multilevel models of the association between patient and hospital covariates with odds of cesarean delivery, overall and among women with no prior cesareans.</p

US 2009–2010 births to all women and women with no prior cesarean: sample size, percentage frequency distribution, and percentage of women with cesarean deliveries and 95% confidence intervals by covariate.

<p>US 2009–2010 births to all women and women with no prior cesarean: sample size, percentage frequency distribution, and percentage of women with cesarean deliveries and 95% confidence intervals by covariate.</p

Hospital variance and 95% credible interval for null analyses and analyses fully adjusted for covariates listed in Table 2, from a multilevel model of births nested in hospitals.

<p>Hospital variance and 95% credible interval for null analyses and analyses fully adjusted for covariates listed in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001745#pmed-1001745-t002" target="_blank">Table 2</a>, from a multilevel model of births nested in hospitals.</p