title: Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact.
abstract: OBJECTIVE
  We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics.
  
  
  METHODS
  Birth certificate and maternal in-patient hospital discharge records for 2004-06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery.
  
  
  RESULTS
  Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023).
  
  
  CONCLUSIONS
  Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate.
authors.affiliation: Bureau of Health Information, Statistics, Research, and Evaluation, Massachusetts Department of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Isabel A
authors.initials: IA
authors.lastname: Cáceres
authors.forename: Mariana
authors.initials: M
authors.lastname: Arcaya
authors.forename: Eugene
authors.initials: E
authors.lastname: Declercq
authors.forename: Candice M
authors.initials: CM
authors.lastname: Belanoff
authors.forename: Vanitha
authors.initials: V
authors.lastname: Janakiraman
authors.forename: Bruce
authors.initials: B
authors.lastname: Cohen
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Ecker
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Smith
authors.forename: S V
authors.initials: SV
authors.lastname: Subramanian
mesh_terms: D000328:Adult; D016477:Artifacts; D002585:Cesarean Section / Q000706:statistics & numerical data* / Q000639:trends; D016208:Databases, Factual; D003953:Diagnosis-Related Groups / Q000706:statistics & numerical data; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D008404:Massachusetts; D011247:Pregnancy