Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison

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Abstract

High rates of cesarean birth are a significant health care quality issue, and birth centers have shown potential to reduce rates of cesarean birth. Measuring this potential is complicated by lack of randomized trials and limited observational comparisons. Cesarean rates vary by provider type, setting, and clinical and nonclinical characteristics of women, but our understanding of these dynamics is incomplete.

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Most cited references 20

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Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues.

Beth Virnig, Michael R Law, Katy Kozhimannil (2013)

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.

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Outcomes of care in birth centers: demonstration of a durable model.

Susan Rutledge Stapleton, Cara Osborne, Jessica Illuzzi (2016)

The safety and effectiveness of birth center care have been demonstrated in previous studies, including the National Birth Center Study and the San Diego Birth Center Study. This study examines outcomes of birth center care in the present maternity care environment. This was a prospective cohort study of women receiving care in 79 midwifery-led birth centers in 33 US states from 2007 to 2010. Data were entered into the American Association of Birth Centers Uniform Data Set after obtaining informed consent. Analysis was by intention to treat, with descriptive statistics calculated for maternal and neonatal outcomes for all women presenting to birth centers in labor including those requiring transfer to hospital care. Of 15,574 women who planned and were eligible for birth center birth at the onset of labor, 84% gave birth at the birth center. Four percent were transferred to a hospital prior to birth center admission, and 12% were transferred in labor after admission. Regardless of where they gave birth, 93% of women had a spontaneous vaginal birth, 1% an assisted vaginal birth, and 6% a cesarean birth. Of women giving birth in the birth center, 2.4% required transfer postpartum, whereas 2.6% of newborns were transferred after birth. Most transfers were nonemergent, with 1.9% of mothers or newborns requiring emergent transfer during labor or after birth. There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies. This study demonstrates the safety of the midwifery-led birth center model of collaborative care as well as continued low obstetric intervention rates, similar to previous studies of birth center care. These findings are particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide. © 2013 by the American College of Nurse-Midwives.

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Performance of disease risk scores, propensity scores, and traditional multivariable outcome regression in the presence of multiple confounders.

Patrick G Arbogast, Wayne Ray (2011)

Propensity scores are widely used in cohort studies to improve performance of regression models when considering large numbers of covariates. Another type of summary score, the disease risk score (DRS), which estimates disease probability conditional on nonexposure, has also been suggested. However, little is known about how it compares with propensity scores. Monte Carlo simulations were conducted comparing regression models using the DRS and the propensity score with models that directly adjust for all of the individual covariates. The DRS was calculated in 2 ways: from the unexposed population and from the full cohort. Compared with traditional multivariable outcome regression models, all 3 summary scores had comparable performance for moderate correlation between exposure and covariates and, for strong correlation, the full-cohort DRS and propensity score had comparable performance. When traditional methods had model misspecification, propensity scores and the full-cohort DRS had superior performance. All 4 models were affected by the number of events per covariate, with propensity scores and traditional multivariable outcome regression least affected. These data suggest that, for cohort studies for which covariates are not highly correlated with exposure, the DRS, particularly that calculated from the full cohort, is a useful tool.

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Author and article information

Journal

Title: Journal of Midwifery & Women's Health

Abbreviated Title: Journal of Midwifery & Women's Health

Publisher: Wiley

ISSN (Print): 1526-9523

ISSN (Electronic): 1542-2011

Publication date Created: January 29 2017

Publication date Created: January 2017

Publication date (Electronic): December 07 2016

Publication date (Print): January 2017

Volume: 62

Issue: 1

Pages: 40-48

Article

DOI: 10.1111/jmwh.12553

PubMed ID: 27926797

SO-VID: fecdf638-5b60-417b-8344-2daa4238d682

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Self URI (article page): https://onlinelibrary.wiley.com/doi/abs/10.1111/jmwh.12553

Self URI (pdf): https://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fjmwh.12553

Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison

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Most cited references 20

Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues.

Outcomes of care in birth centers: demonstration of a durable model.

Performance of disease risk scores, propensity scores, and traditional multivariable outcome regression in the presence of multiple confounders.

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