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Risky obstetric procedure rates vary between rural, urban areas

Monday December 16, 2013
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Rates of unnecessary cesarean section and other potentially risky obstetric procedures show significant variation between rural and urban hospitals in the U.S., according to a study.

Both rural and urban hospitals showed increases in cesarean section over the last decade, while rates of non-indicated induction of labor rose more sharply at rural hospitals, according to the new research in the January issue of the journal Medical Care.

Although the differences in these trends may seem small, the study authors believe they have important implications for maternal and infant health and for public health policy — especially at rural hospitals, which serve a high proportion of Medicaid patients.

Cesarean section rates

Using a national hospital database, the Nationwide Inpatient Sample, Katy B. Kozhimannil, PhD, MPA, of University of Minnesota School of Public Health, and colleagues analyzed data on more than 7 million births between 2002 and 2010. The analysis compared trends in potentially unnecessary cesarean section and induction of labor at rural versus urban hospitals. The study included approximately 6.3 million births at urban hospitals and 840,000 at rural hospitals. About 15% of U.S. infants are born at rural hospitals.

Both rural and urban hospitals showed steady increases in cesarean section rates among low-risk women from 2002 to 2010. By 2010, cesarean sections in low-risk pregnancies accounted for 15.5% of deliveries at rural hospitals and 16.1% at urban hospitals. Rates of non-indicated cesarean section were 16.9% at rural hospitals and 17.8% at urban hospitals.

Rates of medically induced labor with no indication also increased significantly: to 16.5% at rural hospitals and 12% at urban hospitals in 2010. The rate of vaginal birth in women with previous cesarean section decreased over time, to 5% at rural hospitals and 10% at urban hospitals
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Women who gave birth at rural hospitals were younger, more likely to be white, more likely to be on Medicaid and had fewer pregnancy complications compared with women at urban hospitals. After adjustment for these factors, the increase in non-indicated induction of labor occurred faster at rural hospitals: by 5% per year, compared with 4% per year at urban hospitals.

Implications

“This analysis indicates that women giving birth in rural and urban hospitals may experience different childbirth-related benefits and risks,” according to Kozhimannil and coauthors, who believe their findings have important implications for financing and public health policy related to obstetric care.

“Due to Medicaid’s important role in financing childbirth care, particularly in rural hospitals, Medicaid payment policy has great potential to inform and catalyze quality improvement in obstetric care,” the researchers wrote. For example, financial incentives could be put in place to encourage hospitals to follow evidence-based guidelines for cesarean section and induction of labor.

However, such reforms may “face different implementation challenges” at rural versus urban hospitals, according to the authors. They note that more than half of babies born at rural hospitals are covered by Medicaid.

While the differences between rural and urban hospitals may appear small, they likely have a significant impact on the population level. “With approximately 4 million births per year in the United States, a one-percentage-point different in the use of a procedure affects 40,000 women and infants annually,” Kozhimannil said, according to a news release. “Based on our findings, we estimate that differences due to rural or urban location — rather than differences in patient or hospital characteristics — may affect between 24,000 and 200,000 mothers and their babies each year.”

Study abstract: http://bit.ly/19I2zZX


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