Cesarean Section Indicators And Guidelines

National Institute Health, Oct 20, 2006

Rush University, Chicago, IL 60612, USA.

RESEARCH OBJECTIVES: This study investigated the impact of the implementation of obstetrical quality process initiatives, such as cesarean section indicators and guidelines for vaginal birth after cesarean section (VBAC), on the likelihood of birth trauma in newborns whose expected payer for delivery was Medicaid managed care (MMC), Medicaid fee-for-service (MFFS), or private managed care (PMC). STUDY DESIGN: The sample consisted of 281,167 newborn deliveries meeting the following criteria: 500g or more, in California, in 1993, and delivered in an eligible hospital. Eligible hospitals were defined as follows: short-stay, non-federal, 10 or more births in 1993, and respondents to a survey on hospital obstetrical quality initiatives (response rate = 80.3%). Data sources included linked birth certificates, hospital discharge abstracts, Medicaid eligibility files, the 1993 American Hospital Association Survey of Hospitals, and the hospital quality initiatives survey. A hospital quality score (0-19), which represented the number of quality initiatives in place during 1993, was derived from the survey of hospitals. PRINCIPAL FINDINGS: Multiple logistic regression models controlled for maternal age, race, education, maternal risk status, adequacy of prenatal care, infant birthweight, parity, delivery method, infant gender, payer, and hospital teaching status. In deliveries to managed care enrollees (MMC and PMC), each one point increase in hospital quality score resulted in a heightened risk of newborn birth trauma (OR=1.01, p<.0001).

However, in deliveries to Medicaid eligibles (MMC and MFFS), each one point increase in hospital quality score was associated with a decreased risk of birth trauma (OR=0.99, p<.0001). VBAC increased the risk of newborn birth trauma in both Medicaid (MMC/MFFS) eligibles (OR=1.30, p<.0001) and managed care (MMC/PMC) enrollees (OR=1.19, p=.0045). CONCLUSIONS: The design and implementation of obstetrical quality process initiatives, many of which are aimed at lowering cesearean section rates and increasing VBAC rates, may differently affect obstetrical outcomes in different payer groups. RELEVANCE TO CLINICAL PRACTICE, MANAGEMENT AND/OR POLICY: Hospitals planning to implement quality process initiatives for obstetrical care in order to decrease cesarean section rates and other adverse obstetrical complications must carefully weigh such benefits against potential increases in other types of morbidity, which may vary according to population subgroup.

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