Differences Between Hospitals in Cesarean Rates for
Term Primigravidas With Cephalic Presentation
Angela Fischer, MD, MPH, D. Yvette LaCoursiere, MD, MPH, Peter Barnard, CNM,
Lois Bloebaum, BSN, and Michael Varner, MD
OBJECTIVE: The purpose of this study was to quantify patient populations and practice patterns at perinatal centers
with the highest and lowest cesarean delivery rates.
METHODS: The 2 perinatal centers in our state with the
lowest (Hospital A-16.6%) and highest (Hospital B-20.3%)
overall cesarean rates for Robson group 1 (term primigravidas, vertex, spontaneous labor) and group 2 (term primigravidas, vertex, induced labor) were identified. A total of
174 medical records at Hospital A and 150 records at
Hospital B were reviewed. Statistical analysis was performed using independent-sample t tests, ␹2, and multiple
logistic regression.
RESULTS: Indications for cesarean delivery were not different between the 2 groups, with the majority being for
failure to progress in labor and nonreassuring fetal status.
There were no differences between groups in rates of postpartum hemorrhage, chorioamnionitis, or endometritis.
There were no differences in neonatal outcomes.
Although women delivering in hospital A were not more
likely to receive oxytocin augmentation (P ⴝ .291), their
mean maximal oxytocin dosage was higher (14.5 units
compared with 11.6 units, P < .001), and they were more
likely to receive both fetal scalp electrodes (60.9% compared with 37.3%, P < .001) and intrauterine pressure
catheters (63.8% compared with 26.0%, P < .001).
CONCLUSION: Because safe reduction in cesarean delivery
rates for primigravidas will proportionately reduce the
number of repeat cesarean delivery required, benchmarking practices as described in this study can be considered in
obstetric practices interested in long-term reductions of
their cesarean delivery rates. (Obstet Gynecol 2005;105:
816 –21. © 2005 by The American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: III
Decreasing the overall cesarean delivery rate continues
to be a major goal for obstetricians and health policy
From the Department of Obstetrics and Gynecology, University of Utah School of
Medicine, and Utah Department of Health, Salt Lake City, Utah.
Presented in part at the annual meeting of the Society for Gynecologic Investigation,
Houston, Texas, March 24-27, 2004.
816
VOL. 105, NO. 4, APRIL 2005
© 2005 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
makers since the national cesarean delivery rate peaked
in 1985 (23% of all deliveries).1,2 With the wide-scale
endorsement of vaginal birth after cesarean delivery
(VBAC) in the 1980s as a means to reduce the number of
repeat cesarean deliveries3 plus the adoption of active
labor management protocols to decrease the primary
cesarean delivery rate,4,5 many centers across the country have found that cesarean delivery rates can be reduced without untoward harm to the mother or the
infant.1,6,7
Nonetheless, cesarean rates vary substantially between geographic areas in the United States and often
vary substantially between hospitals in the same community.8 Numerous factors contribute to these differences,
including the availability of ancillary staff (anesthesia,
pediatrics, etc), training and experience of the surgeon(s), and characteristics of particular patient populations.9 The recent VBAC policy changes by the American College of Obstetricians and Gynecologists have
also increased the number of repeat cesarean deliveries
both nationally and in our state.10,11
The Robson cesarean classification system was developed as a way to categorize the population of pregnant
women requiring cesarean delivery and thereby to compare cesarean rates among equivalent subpopulations.12
In this system any cesarean delivery can be placed in 1,
but only 1, of 10 mutually exclusive patient population
categories (Table 1). Although not yet widely applied to
U.S. populations, this classification system could be of
value for defining and comparing optimal cesarean delivery rates for different patient populations.
Using birth certificate data and the Robson cesarean
classification system12 we previously surveyed the cesarean rates in the 6 perinatal centers in our state.8 The
average cesarean delivery rates for Robson group 1 and
2 were 12.7% ⫾ 3.0 and 13.7% ⫾ 3.3. We found that
rates varied substantially between centers both for Robson group 1 (term primigravidas with vertex presentation in spontaneous labor), 7.8% (Hospital A) to 16.3%
(Hospital B), and Robson group 2 (term primigravidas
0029-7844/05/$30.00
doi:10.1097/01.AOG.0000156299.52668.e2
Table 1. Robson Cesarean Classification12
Group
Description
1
Nullipara, ⬎ 37 weeks, single, cephalic
presentation, spontaneous labor
Nullipara, ⬎ 37 weeks, single, cephalic
presentation, induced labor or cesarean
delivery before labor
Multipara, NO previous cesarean, ⬎ 37
weeks, single, cephalic presentation,
spontaneous labor
Multipara, NO previous cesarean, ⬎ 37
weeks, single, cephalic presentation,
induced labor or cesarean delivery
Multipara, previous cesarean, ⬎ 37weeks,
single, cephalic presentation
Nullipara, single breech presentation
Multipara, single breech presentation
Multiple gestation (with or without previous
cesarean)
Singleton pregnancy, oblique or transverse lie
(excluding breech, with or without previous
cesarean)
Single, cephalic pregnancy, ⬍ 37 weeks
(including previous cesarean)
2
3
4
5
6
7
8
9
10
with vertex presentation whose labors were induced),
8.3% (Hospital A) to 18.3% (Hospital B). The overall
cesarean rates, regardless of Robson criteria varied from
16.6% at Hospital A to 20.3% at Hospital B. The objective of this study was to quantify patient populations and
practice patterns at the institutions with the highest and
lowest cesarean delivery rates in the State of Utah.
METHODS
The State of Utah has 6 designated perinatal centers.
When birth certificate data from 1998 to 2000 (n ⫽
127,462) from these 6 hospitals were compared using
Robson categories 1 and 2, one hospital (Hospital A) had
the lowest cesarean rates in both categories and another
hospital (Hospital B) had the highest cesarean rates in
both categories. The protocol was reviewed and approved by the Utah Department of Health and the
University of Utah Institutional Review Boards.
One hundred temporally consecutive maternal and
fetal medical records identified from State of Utah birth
certificate data were requested from each of the 2 Robson
criteria from both Hospital A and Hospital B. The sampling
technique oversampled for cesarean delivery, such that one
half of each sample was delivered by cesarean.
Inclusion criteria were the following: primigravidas
with singleton vertex presentations at more than 37
weeks gestation who were admitted in spontaneous labor (Robson group 1) or for induction of labor (Robson
group 2). Medical records were reviewed for baseline
VOL. 105, NO. 4, APRIL 2005
demographic characteristics, antepartum and medical
complications, labor management variables, and neonatal outcomes. Demographic characteristics included maternal age, gestational age at delivery, maternal body
mass index (BMI) at delivery, past and current tobacco
use, number of prenatal care visits, and the woman’s
choice of perinatal health care provider.
Method of delivery was determined (spontaneous
vaginal delivery, forceps- or vacuum-assisted vaginal
delivery, cesarean delivery) as were the specifics of intrapartum management, including oxytocin use, maximal
oxytocin dose and duration, fetal scalp electrode or external
monitoring to assess fetal heart rate, intrauterine pressure
catheter placement, and corresponding maximal Montevideo units. Indications for cesarean delivery were recorded. Records were also reviewed for the occurrence of
postpartum hemorrhage requiring transfusion, chorioamnionitis, and endometritis. Neonatal complications reviewed included birth weight, 1- and 5-minute Apgar
scores, and need for newborn intensive care unit admission.
The calculation of the sample size to detect a 50%
difference in intrapartum management characteristics
was 162 total women per group at power of 80% and a
type I error of 0.05. The specific characteristics compared for sample size calculation were intrauterine pressure catheter and fetal scalp electrode use; both the fetal
scalp electrode and intrauterine pressure catheter groups
were each estimated to have a 30% usage rate at one
hospital. We estimated that an increase to 45% would be
a clinically meaningful increase.
Data analysis was performed using SPSS 12.0 (SPSS
Inc., Chicago, IL). Continuous normal data were described using means and standard deviations, then analyzed using independent t tests. Categorical variables were
described using frequency and percentages. Statistical analysis on these variables was performed using ␹2 analyses
(uncorrected or Fisher exact test when expected cells were
less than 5), For analyses using t tests and ␹2, statistical
significance was set at P ⬍ .05. An a priori list of independent and dependent variable were selected for the multiple
logistic regression models. Scale variables were coded using
dummy variables (Tobacco, Robson, and Hospital). Maternal age was included as a continuous variable. The
variables were entered in block. Statistical hypotheses were
tested using 2-tailed 95% confidence intervals.
RESULTS
A total of 174 records were reviewed at Hospital A and
150 records from Hospital B. At Hospital A, 78 records
fell into Robson category 1, with 96 in Robson category
2. At Hospital B, 50 records fell into Robson category 1,
with 100 records in Robson category 2. All patients who
Fischer et al
Cesarean Rates and Cephalic Presentation
817
Table 2. Maternal Demographics, Practice Patterns, and Indication for Cesarean Delivery
Hospital A
(Low Cesarean Delivery)
n ⫽ 174
Maternal demographics
Maternal age (y)
Gestational age (wk)
Delivery body mass index (m/kg2)
Past tobacco use
Current tobacco use
Prenatal care by obstetrician
⬎ 12 prenatal visits
Practice patterns
Oxytocin augmentation
Fetal scalp electrode use
Intrauterine pressure catheter use
Maximal Montevideo units
Maximal oxytocin dose (mIU)
Indication for induction
Preeclampsia (% of indications)
Nonreassuring fetal status
Prolonged rupture of membranes
Post dates
Fetal
Elective
Indication for cesarean delivery
Failure to progress
Nonreassuring fetal status
Other
Hospital B
(High Cesarean Delivery)
n ⫽ 150
P
23.7
39.8
29.7
0
1
169
143
(⫾3.9)
(⫾0.9)
(⫾4.9)
(0)
(0.6)
(97.1)
(82.0)
25.0
39.3
30.1
5
17
139
113
(⫾5.3)
(⫾1.1)
(⫾5.5)
(3.3)
(11.3)
(92.7)
(75.2)
.008
⬍ .001
.540
.021
⬍ .001
.065
.131
132
106
111
252.2
14.5
(75.9)
(60.9)
(63.8)
(⫾81.1)
(⫾5.9)
106
56
39
230.0
11.6
(70.7)
(37.3)
(26.0)
(58.7)
(⫾7.2)
.291
⬍ .001
⬍ .001
.121
⬍ .001
(19.7)
(3.1)
(9.5)
(26.1)
(16.7)
(27.1)
24
8
8
23
11
26
(24.0)
(8.0)
(8.0)
(23.0)
(11.0)
(26.0)
.477
.138
.732
.621
.439
.864
(41.1)
(53.4)
(15.6)
23
32
18
(32.9)
(45.7)
(25.7)
.436
.543
.086
19
3
9
25
16
26
n ⫽ 96
n ⫽ 70
30
39
11
n ⫽ 100
n ⫽ 73
Values are mean (⫾ standard deviation) or n (%).
were classified into Robson cesarean classifications 3
through 10 (Table 1) were excluded from the analysis.
For Hospital A (low cesarean delivery rate), 12 patient
records belonged to Robson categories 3–10 (6% misclassification rate), and a total of 14 were unavailable for
analysis. At Hospital B (high cesarean delivery rate), a
total of 21 records belonged to Robson categories 3–10
(10.5% misclassification rate), and 29 were unavailable
for analysis.
Table 2 shows that women delivering at Hospital A
were significantly younger (23.7 compared with 25.0
years, P ⫽ .008) and had higher mean gestational ages
(39.8 compared with 39.3 weeks, P ⬍ .001). Women at
Hospital A were also significantly less likely to have
current or past use of tobacco. The 2 groups were not
different in any characteristics of percentage of total
prenatal care visits (P ⫽ .131), level of care provider (P ⫽
.065), or BMI (P ⫽ .540). There was no difference
between hospitals in the indication for induction.
There were significant differences in labor management characteristics between the 2 hospitals (Table 2).
Although women delivering in Hospital A (low cesarean
rates) were not more likely to receive oxytocin augmentation (75.9% vs 70.7%, P ⫽ .291), their mean maximal
oxytocin dosage was higher (14.5 units compared with
818
Fischer et al
Cesarean Rates and Cephalic Presentation
11.6 units, P ⬍ .001). There was no difference in the
duration of oxytocin administration. Hospital A used an
active labor management algorithm similar to that described by the National Maternity Hospital in Dublin.4
Women at Hospital A were more likely to receive both
fetal scalp electrodes (60.9% compared with 37.3%, P ⬍
.001) and intrauterine pressure catheters (63.8% compared with 26.0%, P ⬍ .001). The unadjusted odds of
having a fetal scalp electrode or intrauterine pressure
catheter at the low cesarean delivery rate hospital were
2.78-fold (95% confidence interval 1.72, 4.49) and 5.01fold (95% confidence interval 3.03, 8.34) higher, respectively, than at the high cesarean delivery hospital. The
maximal Montevideo units at Hospital A were not statistically different from Hospital B (252.2 compared with
230.0, respectively). Fetal scalp electrode and intrauterine pressure catheter remained significantly higher at
Hospital A after controlling for maternal age, tobacco
use, gestational age at delivery, and Robson criteria
(Table 3).
The oversampling technique yielded 70 women from
the random sample of patients at Hospital A and 73 at
Hospital B who underwent cesarean delivery. Because
cesarean deliveries were oversampled, cesarean delivery
rates cannot be calculated from this sample. Cesarean
OBSTETRICS & GYNECOLOGY
Table 3. Multiple Logistic Regression Model of Fetal Scalp Electrode and Intrauterine Pressure Catheter Use
Adjusted Odds Ratio (95% Confidence Interval)
Fetal Scalp Electrode Use
n ⫽ 320
Intrauterine Pressure Catheter Use
n ⫽ 324
1.00 (0.95–1.06)
1.01 (0.95–1.07)
1.36 (0.48–3.92
5.20 (0.57–47.85)
4.33 (2.56–7.34)
4.17 (2.45–7.10)
0.52 (0.14–1.98)
...
4.84 (2.74–8.55)
7.29 (4.43–14.18)
Maternal age
Tobacco
Past
Current*
Robson (reference ⫽ 1)
Hospital (reference ⫽ B)
* There were no current smokers in women without an intrauterine pressure catheter at hospital A; data have been excluded.
delivery rates at both hospitals were previously identified as follows: Hospital A 7.8% (Robson 1) and 8.3%
(Robson 2) and Hospital B 16.3% (Robson 1) and 18.3%
(Robson 2).8 Table 2 shows that indications for cesarean
delivery were not different between the 2 groups, with
the majority being for failure to progress in labor (A ⫽
41.1% compared with B ⫽ 32.9%, P ⫽ .436) and nonreassuring fetal monitor tracings (A ⫽ 53.4% compared
with B ⫽ 45.7%, P ⫽ .543).
When comparing Hospital A to Hospital B, there were
no differences in postpartum hemorrhage requiring
transfusion (P ⫽ .999), chorioamnionitis (P ⫽ .690), or
endometritis (P ⫽ .627) (Table 4). No statistically significant differences develop for these complications when
controlling for maternal age, tobacco use, gestational age
at delivery, and Robson criteria. As shown in table 4,
there were no differences in neonatal outcomes, including birth weight (P ⫽ .260), 1- or 5-minute Apgar scores
less than 7 (P ⫽ .664 and P ⫽ .127, respectively), and
neonatal intensive care unit admissions (P ⫽ .065).
DISCUSSION
Although not widely used in the United States, the
Robson cesarean delivery classification system12 allows
comparison of cesarean rates within specific subsets of an
obstetric population and thereby obviates many of the
historic arguments that have arisen when comparing
overall cesarean rates between different populations. By
reviewing patient demographics and practice patterns for
2 similar patient populations (Robson groups 1 and 2,
Table 1) we sought to identify issues that could explain
the greater than 2-fold differences in cesarean rates between Hospital A (low cesarean rates) and Hospital B
(high cesarean rates).
As described by others, we have found only a modest
correlation between birth certificate data and actual medical record reviews. Of the 100 patients in each of the 2
groups at each hospital that were identified from birth
certificate data, we were only able to find records on
89.3% of women. Of these, 90.7% were correctly classified by Robson criteria.
Modest differences were identified in the primigravid
patient populations between Hospital A and Hospital B.
Although statistically significant, it seems unlikely that
an average maternal age difference of 1.3 years or a
difference of a few days gestational age would explain a
cesarean rate difference in excess of 2-fold between the 2
hospitals. Likewise, although women at Hospital B were
more likely to smoke, there is no reason to think that this
would increase the risk of operative delivery to the extent
Table 4. Obstetric and Neonatal Complications
Hospital A
(Low Cesarean Delivery)
n ⫽ 174
Obstetric
Postpartum hemorrhage requiring transfusion
Chorioamnionitis
Endometritis
Neonatal
Birth weight (g)
1-minute Apgar ⬍ 7
5-minute Apgar ⬍ 7
NICU admission
Hospital B
(High Cesarean Delivery)
n ⫽ 150
P
1
4
3
(0.6)
(2.3)
(1.7)
0
2
1
(0)
(1.3)
(0.6)
.999
.690
.627
3,441
10
0
5
(⫾442)
(5.7)
0
(2.9)
3,384
7
2
11
(⫾465)
(4.7)
(1.3)
(7.3)
.260
.664
.127
.065
NICU, neonatal intensive care unit.
Values are mean (⫾ standard deviation) or n (%).
VOL. 105, NO. 4, APRIL 2005
Fischer et al
Cesarean Rates and Cephalic Presentation
819
observed. In fact, there is reasonable evidence that smokers
are less likely to require operative delivery than are women
who do not smoke,13 presumably as a result of the decreased average birth weight associated with smoking.
Another factor that might explain a higher cesarean
delivery rate at Hospital B is its more racially diverse
patient population as compared with Hospital A. Thom
et al14 showed that cesarean delivery rates are significantly higher in black primigravidas compared with
whites. Racial characteristics of the overall populations
studied at both Hospital A and B were not analyzed,
however, and this is a potential limitation of this study
that might potentially have served to explain a higher
cesarean delivery rate at Hospital B. Caucasian women
by far make up the majority of patients at both facilities
and lessen this potential effect.
We hoped to identify practice patterns that could
safely reduce cesarean rates and serve as a benchmark
for our region. The higher average oxytocin dose and
the more frequent use of intrauterine pressure catheters
and fetal scalp electrodes in Hospital A confirm that that
institution’s active labor management protocol may be
contributing to its lower cesarean delivery rate. The
equivalence of other maternal or neonatal outcomes in
Hospital A suggests that active labor management practices can lower the cesarean delivery rate within Robson
categories 1 and 2 without obvious increased risks.
The differences in practice patterns in this study may
have been attenuated given the somewhat increased
proportion of Robson 2 (induced) subjects collected at
Hospital B. This difference does not affect the cesarean
rates documented at these facilities, because these rates
were stratified by Robson criteria. The increase in the
proportion of women induced may increase the need for
intervention, such as oxytocin, intrauterine pressure
catheter, or fetal scalp electrode use. This would have a
diminutive effect on the overall difference between
groups. Despite this, the results remain statistically significant.
The overall results of this study confirm previous
reports that cesarean delivery rates can be decreased
with the active management of labor.1,2,6,14 –23 Active
management of labor as described by O’Driscoll et al2,21
consists of strict criteria for the diagnosis of labor,
prompt intervention with high-dose oxytocin in the
event of inefficient uterine action or ruptured membranes, and a dedicated commitment not to leave a
woman unattended during labor.2
Although our results suggest the lower cesarean delivery rate at Hospital A is the result of the institutional
protocol of active labor management at Hospital A, it is
possible that other factors might explain some proportion of this decrease. There are data that indicate chang-
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Fischer et al
Cesarean Rates and Cephalic Presentation
ing physician behavior is also effective at lowering the
cesarean rate.22 Myers and Gleicher1 demonstrated that
strict adherence by physicians to defined labor management parameters resulted in a significant reduction in the
cesarean rate at their institution. Other factors potentially to consider in studies comparing cesarean delivery
rates between institutions are the number of obstetricians
on staff and how many patients they have, what the
nursing care is like, what the litigation history has been at
a particular institution, etc. Perhaps there are combinations of these factors occurring at Hospital A that contribute to a lower cesarean delivery rate compared with
Hospital B. This study did not address any of these
potential factors that might serve to either increase or
reduce the cesarean delivery rate, and this represents a
potential limitation of this study.
We have not identified the 2 specific hospitals studied
in this report and have no intention of doing so. However, we have initiated a statewide education program
consisting of presentations at hospital staff meetings by
the authors of this study and will circulate reprints of this
manuscript to all obstetric care providers and hospital
nursing staff in Utah.
In conclusion, reviewing labor management practices
by specific patient subgroups can identify issues that
could change practice patterns and safely lower cesarean
rates. Comparison of cesarean rates by specific Robson
criteria can also minimize the contention that differences
in patient populations are responsible for differences in
cesarean rates. In our study, Hospital A’s active labor
management practices of oxytocin administration and
increased use of internal monitoring (intrauterine pressure catheter or fetal scalp electrode) resulted in higher
vaginal delivery rates for primigravidas with no increased maternal or neonatal morbidity. Because safe
reduction in cesarean delivery rates for primigravidas
will proportionately reduce the number of repeat cesarean delivery required (and therefore contribute to lowering the overall cesarean delivery rate), benchmarking
practices as described in this study can be considered in
obstetric practices interested in long-term reductions of
their cesarean delivery rates.
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Address reprint requests to: D. Yvette LaCoursiere MD,
MPH, University of Utah, Department of Obstetrics and Gynecology, 30N 1900 E Suite 2B200, Salt Lake City, UT 84108;
e-mail: [email protected].
Received August 16, 2004. Received in revised form December 13,
2004. Accepted December 16, 2004.
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Cesarean Rates and Cephalic Presentation
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