Outcomes/Effectiveness Research

Private nonteaching hospitals have higher cesarean delivery rates than other hospitals for Medicaid-insured women

Women undergoing cesarean delivery have higher rates of infection and take longer to heal after delivery than women who have vaginal deliveries. They also are more likely to have complications in later pregnancies from repeat cesarean delivery and have an increased risk of abnormal placentation and ectopic pregnancy. Private nonteaching hospitals, which now care for the largest proportion of Medicaid-insured women, have higher cesarean delivery rates for these women compared with other types of hospitals, concludes a study by the Patient Outcomes Research Team (PORT) on Variations in Management of Childbirth and Patient Outcomes. This is important, since large numbers of obstetric Medicaid patients are being systematically transferred from public hospitals to private nonteaching hospitals, notes PORT researcher, Katherine L. Kahn, M.D., of RAND and the University of California, Los Angeles.

With support from the Agency for Health Care Policy and Research (PORT contract 290-92-0039) and the Robert Wood Johnson Foundation, the researchers retrospectively studied California discharge data for 92,800 women who delivered babies at 78 hospitals in Los Angeles County during 1991. According to Kimberly D. Gregory, M.D., M.P.H., a team member supported by the Robert Wood Johnson Foundation Minority Faculty Development Award, Medicaid-insured women who gave birth in private nonteaching hospitals had a lower prevalence of clinical conditions that are typically associated with cesarean deliveries when compared with women who delivered their babies at public, private teaching, and HMO hospitals.

After adjusting for the women's clinical and sociodemographic characteristics, the researchers found that the Medicaid-insured women who delivered their babies in private nonteaching hospitals had an overall cesarean delivery rate that was 2 to 2.5 times as great as that of similar women who delivered at public hospitals (24.5 percent vs. 9 percent). The adjusted cesarean delivery rate was 8 percent in private teaching hospitals and 12 percent in HMO hospitals. These data cannot distinguish if cesarean deliveries are being overused in private nonteaching hospitals or underused in other types of hospitals. Based on the 1995 mean per diem hospital reimbursement rate for Medicaid patients ($821) and the mean 3-day hospital stay for cesarean delivery versus the 1-day stay for vaginal deliveries, the difference in the calculated cesarean rates by hospital type translated into about $13.6 million in additional health care expenses for obstetric services in Los Angeles County.

For more details, see "Cesarean deliveries for Medicaid patients: A comparison in public and private hospitals in Los Angeles County," by Dr. Gregory, Emily Ramicone, M.S., Linda Chan, Ph.D., and Dr. Kahn, in the May 1999 American Journal of Obstetrics and Gynecology 180, pp. 1177-1184.

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