title: Hospital variation in maternal complications following caesarean delivery in the United States: 2006-2012.
abstract: OBJECTIVE
  To assess hospital variability in and patient and hospital factors associated with caesarean delivery (CD) complications.
  
  
  METHODS
  Population-based cohort.
  
  
  METHODS
  United States delivery admissions.
  
  
  METHODS
  Women who underwent a CD between 2006 and 2012.
  
  
  METHODS
  Hospital-specific random-effects log-linear regression models were developed to account for patient, obstetric, and hospital risk factors related to a composite complication outcome including infection, haemorrhage, surgical complications and prolonged hospital stay. Between-hospital variability in rates of CD complications was also estimated.
  
  
  METHODS
  Composite complication rate.
  
  
  RESULTS
  Among 1 339 397 women who underwent CD in 457 hospitals, 6.4% (n = 85 838) experienced a complication. The most frequent complications were haemorrhage, transfusion, length of stay >7 days, and endometritis. Complications were strongly associated with the presence of obstetric factors and pre-existing medical conditions. Complication rates were 54% higher among black (8.8%) than white (5.7%) women (P < 0.001), and were more common in teaching (8.1%) than non-teaching (5.4%) hospitals (P < 0.001). In an adjusted model, the mean complication rate was 6.7%. A small proportion of hospitals (4.8%) had a complication rate greater than twice the mean (≥13.4%). Complications were strongly associated with the presence of obstetrical factors and pre-existing medical conditions.
  
  
  CONCLUSIONS
  CD complication rates are strongly associated with patient and obstetric factors. While CD complication rates may be a quality metric of limited utility given the low rate of complications across most hospitals, a small number of hospitals demonstrate particularly high rates of complications. Review of CD complication rates may be an important aspect of quality assurance processes for these centres.
  
  
  CONCLUSIONS
  A small number of hospitals demonstrate particularly high rates of caesarean complications.
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Moroz
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Wright
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: C V
authors.initials: CV
authors.lastname: Ananth
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Friedman
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002585:Cesarean Section / Q000009:adverse effects* / Q000706:statistics & numerical data; D004716:Endometritis / Q000453:epidemiology; D005260:Female; D006771:Hospitals, Maternity / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008875:Middle Aged; D011183:Postoperative Complications; D019106:Postoperative Hemorrhage / Q000453:epidemiology; D011247:Pregnancy; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Caesarean complications; care quality; hospital variation; obstetric variation