title: Evaluating risk-adjusted cesarean delivery rate as a measure of obstetric quality.
abstract: OBJECTIVE
  To validate the risk-adjusted cesarean delivery rate as a measure of obstetric quality through its association with maternal and neonatal outcomes for all pregnancies (model 1) and in primiparous patients with singleton pregnancies (model 2).
  
  
  METHODS
  We constructed a population-based cohort of 845,651 patients from 401 hospitals representing all deliveries in California and Pennsylvania between 2004 and 2005. We used linked birth certificate and hospital admission records for mother and neonate to estimate the correlation between risk-adjusted cesarean delivery and a composite of adverse maternal outcomes, adverse neonatal outcomes, and four obstetric patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ).
  
  
  RESULTS
  In both models, risk-adjusted cesarean delivery rates were negatively correlated with both the maternal and neonatal composite outcomes and the AHRQ patient safety indicators for birth trauma, injury with instrumented vaginal delivery, and cesarean delivery. Approximately 60% of the 107 hospitals with lower-than-expected risk-adjusted cesarean delivery rates had higher-than-expected rates of at least one of the six adverse outcomes, compared with 19.6% of the hospitals with higher-than-expected risk-adjusted cesarean delivery rates and 36.1% of the hospitals with expected rates (P<.001).
  
  
  CONCLUSIONS
  Lower-than-expected risk-adjusted cesarean delivery rates in all patients or when restricted to a more homogeneous group of primiparous patients with term singleton pregnancies are associated with higher-than-expected adverse maternal or neonatal outcomes. Higher-than-expected risk-adjusted cesarean delivery rates do not result in improved outcomes.
authors.affiliation: From the Department of Obstetrics and Gynecology, University of Pennsylvania; the Leonard Davis Institute of Health Economics, University of Pennsylvania; the Center for Outcomes Research, Children's Hospital of Philadelphia; and the Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Sindhu K
authors.initials: SK
authors.lastname: Srinivas
authors.forename: Corinne
authors.initials: C
authors.lastname: Fager
authors.forename: Scott A
authors.initials: SA
authors.lastname: Lorch
mesh_terms: D002140:California; D002585:Cesarean Section / Q000706:statistics & numerical data*; D015897:Comorbidity; D005260:Female; D006801:Humans; D009774:Obstetrics / Q000592:standards*; D017063:Outcome Assessment, Health Care; D010298:Parity; D010414:Pennsylvania; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000601:surgery; D011256:Pregnancy Outcome; D019984:Quality Indicators, Health Care; D020379:Risk Adjustment
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