The following is a summary of “Assessing hospital differences in low-risk cesarean delivery metrics in Florida,” published in the December 2023 issue of Obstetrics and Gynecology by Obure, et al.
Unnecessary cesarean deliveries pose risks to maternal and neonatal health, contributing to increased morbidities and mortalities. Florida reported a cesarean delivery rate of 35.9% in 2020, ranking as the third highest nationwide. A targeted strategy to enhance quality care involves reducing primary cesarean deliveries in low-risk births, notably nulliparous, term, singleton, vertex cases. Nationally recognized hospital metrics for low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing these metrics is vital for precise and timely measurement, supporting collective quality improvement initiatives across multiple hospitals to lower low-risk cesarean delivery rates and enhance maternal care quality. For a study, researchers sought to evaluate discrepancies in hospital low-risk cesarean delivery rates in Florida by employing five distinct metrics of low-risk cesarean delivery rates. These metrics were based on risk methodology, including nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and data sources, encompassing linked birth certificate and hospital discharge records, as well as hospital discharge records alone.
The study employed a population-based approach, examining live births in Florida from 2016 to 2019 to compare five methodologies for calculating low-risk cesarean delivery rates. Analyses utilized both linked birth certificate data and inpatient hospital discharge data. The five metrics for low-risk cesarean delivery were delineated as follows: the nulliparous, term, singleton, vertex birth certificate measure; Joint Commission–linked, which applied Joint Commission exclusions; Society for Maternal-Fetal Medicine–linked, utilizing Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. The nulliparous, term, singleton, vertex birth certificate metric relied solely on birth certificate data, excluding linked hospital discharge data. While designated as nulliparous, term, singleton, vertex, it did not exclude other high-risk conditions. Conversely, the Joint Commission–linked and Society for Maternal-Fetal Medicine–linked measures utilized data elements from the full-linked dataset to identify nulliparous, term, singleton, and vertex cases while excluding several high-risk conditions. The last two measures, Joint Commission hospital discharge with Joint Commission exclusions and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions, were based solely on hospital discharge data, without utilizing linked birth certificate data. These measures generally reflected term, singleton, and vertex cases due to inadequate parity assessment on hospital discharge data. Hospital variations between these five measures were assessed overall and at the neonatal intensive care unit level.
The study found a consistent decrease in the median rates of low-risk cesarean deliveries across different metrics. The median rates decreased from 30.7% for nulliparous, term, singleton, and vertex birth certificates (NTSV-BC) to 18.1% for Society for Maternal-Fetal Medicine hospital discharge. Similar trends were observed across neonatal intensive care unit levels, with Level II having the highest median rates for most metrics. A comparison of the median number of low-risk births revealed a decrease across linked and hospital discharge measures, indicating a wide gap in cesarean delivery rates between linked and hospital discharge metrics. However, this disparity narrowed as hospital rates increased.
Monitoring low-risk cesarean delivery rates using the nulliparous, term, singleton, and vertex birth certificate metrics proved accurate and provided timely assessment for Florida hospitals. These rates were comparable with low-risk metrics derived from linked data sources. Metrics derived from the same data source generally exhibited similar rates, with the Society for Maternal-Fetal Medicine metric showing the lowest rates. However, metrics relying solely on hospital discharge data led to substantially underestimated rates due to the inclusion of multiparous women, highlighting the importance of cautious interpretation of such metrics.