Evaluating rates and factors associated with cesarean section and inpatient cost among low-risk deliveries in selected U.S. states.

introductionCesarean sections are commonly performed in the United States, including among patients for whom vaginal delivery may be clinically feasible. This study aimed to evaluate rates and factors associated with cesarean section use and inpatient cost among low-risk deliveries in selected U.S. states.

methodsThis was a retrospective, cross-sectional analysis using Healthcare Cost and Utilization Project (HCUP) State Inpatient database for Maryland, Florida, and Wisconsin between January 1, 2017, and December 31, 2020. American Hospital Association (AHA) data and median household income quartiles based on the Agency for Healthcare Research and Quality's (AHRQ) 2018 estimates were included in this study to assess hospital and patient neighborhood characteristics. AHA data was linked to HCUP data using the hospital identifier number. Median household income quartiles were linked to HCUP using ZIP codes. A multivariable generalized estimating equations regression model including a random intercept for hospitals was used to identify patient- and hospital-level characteristics associated with the use of cesarean section.

results245,383 women who underwent a delivery between 2017 and 2020 were included in the analysis. Of these women, 8.1% had cesarean section and 91.9% had vaginal delivery. Mean age was 26.9 (SD ± 4.41) years for cesarean section and 26.9 (SD± 4.37) years for vaginal delivery. An increasing rate of cesarean section was detected during the study period. Higher rates of cesarean section were found among Black and Hispanic women compared to White and Asian, and among women with lower income. Hospitals in Florida had the highest cesarean section rate of 9.4% among low-risk women while Maryland and Wisconsin had rates of 6.3% and 5.3%, respectively. Being Hispanic or Black, having private insurance, and giving birth in a for-profit hospital were associated with higher cesarean section utilization after controlling patient- and hospital-level factors. DISCUSSION: A range of clinical and policy interventions have been implemented over the past decade to reduce cesarean sections among low-risk deliveries; however, we still identified an increasing rate of cesarean section among low-risk women between 2017 and 2020 in select U.S. states. There is an emergent need to revisit policies and interventions that impact cesarean section in these states. Women with low socioeconomic status were more vulnerable to have cesarean sections. Identifying variation in cesarean delivery rates among low-risk populations may inform future efforts to improve maternal care quality.