OBJECTIVE
To validate the risk- adjusted cesarean delivery rate as a measure of obstetric quality through its association with maternal and neonatal outcomes for all pregnancies (model 1) and in singleton primiparous patients (model 2).
METHODS
We constructed a population-based cohort of 845,651 patients from 401 hospitals representing all deliveries in California and Pennsylvania between 2004 and 2005. We used linked birth certificate and hospital admission records for mother and infant to estimate the correlation between risk-adjusted cesarean delivery and a composite of adverse maternal outcomes, adverse neonatal outcome, and four obstetric patient safety indicators from The Agency for Healthcare Research and Quality (AHRQ).
RESULTS
In both models, risk-adjusted cesarean delivery rates were negatively correlated with both the maternal and neonatal composite outcomes and the AHRQ patient safety indicators for birth trauma, injury with instrumented vaginal delivery and cesarean delivery. Approximately 60% of the 107 hospitals with lower-than-expected risk-adjusted cesarean delivery rates had a higher-than-expected rate of at least one of the six adverse outcomes, compared to 19.6% of the hospitals with a higher-than-expected, risk-adjusted cesarean delivery rate and 36.1% of the hospitals with expected rates (p<0.001).
CONCLUSION
Lower-than-expected, risk-adjusted cesarean delivery rates in all patients or when restricted to a more homogeneous group of term singleton primiparous patients are associated with higher-than-expected adverse maternal or neonatal outcomes. Higher-than-expected risk-adjusted cesarean delivery rates do not result in improved outcomes.
Racial/ethnic differences exist in patterns of periviable resuscitation, which may reflect underlying differences in patient preference. Alternatively, institutional practices or resources may account for these differences. These findings have important implications for patient care and institutional practice. Our results lay the foundation for additional work to investigate how social, cultural, and institutional factors influence patient-provider decision-making regarding periviable care.
Despite a decline in the late 1990s, early discharge of late-preterm newborns remains common. We observe differences according to state, hospital teaching affiliation, and patient insurance. Additional research on the safety and appropriateness of early discharge for this population is necessary.
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