Evaluate Trends and Factors Associated with C-section and Inpatient Cost Among Low-risk Deliveries in Selected U.S. States

Introduction Cesarean deliveries (c-sections) are surgical procedures used when vaginal delivery is no longer a safe option. The c-section risks should be considered on an individual basis; however, frequent c-sections in low-risk deliveries may lead to harm. Factors associated with increasing c-section utilization remain unclear especially among healthy women. Methods This 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 quantiles 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 c-section. Results 245,620 women who underwent their first delivery between 2017 and 2020 were included in the analysis. Of these women, 8.1% had c-section and 91.9% had natural delivery. Mean age was 26.9 (SD ± 4.41) years for c-section and 26.9 (SD ± 4.37) years for natural delivery. An increasing trend of c-section was detected during the study period. Higher rates of c-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 c-section rate of 10.4% among low-risk women while Maryland and Wisconsin had rates of 6.8% and 5.7%, respectively. Being Hispanic or Black, having private insurance, and giving birth in a for-profit hospital were associated with higher c-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 unnecessary c-sections; however, we still identified an increasing trend of c-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 c-section in these states. Women with low socioeconomic status were more vulnerable to have unnecessary c-section. Lowering c-section rates could also lead to reallocating recourses to populations in need thus reducing health disparities.