# Presentation: 892914

## Persistent Cesarean Delivery Risk Among Florida Women: Who’s Next?

**Dave Goodman, MS PhD**
**William Sappenfield, MD MPH**
**Dan Thompson, MPH**
**Division of Family Health Services, Florida Department of Health**
**Charles Mahan, MD**
**University of South Florida, College of Public Health**
**Lori Reeves, MPH**
**March of Dimes, Florida Chapter**

## Florida DOH
Infant, Maternal, and Reproductive Health  
Planning, Evaluation, and Data Analysis
Dr. John Middaugh, State Epidemiologist
Florida Partners
March of Dimes Preterm Birth Prevention Statewide Workgroup
Lawton Rhea Chiles Center for Healthy Mothers and Babies 
National Partners
Michael Kogan, HRSA, MCHB
Carol Sakala and Maureen Corry, Childbirth Connection
Eugene DeClercq, Boston University
Charles Denk, New Jersey Department of Health
Joann Petrini, National Chapter March of Dimes

**Infant, Maternal, and Reproductive Health  **
**Planning, Evaluation, and Data Analysis**
**Dr. John Middaugh, State Epidemiologist**
**Florida Partners**
**March of Dimes Preterm Birth Prevention Statewide Workgroup**
**Lawton Rhea Chiles Center for Healthy Mothers and Babies **
**National Partners**
**Michael Kogan, HRSA, MCHB**
**Carol Sakala and Maureen Corry, Childbirth Connection**
**Eugene DeClercq, Boston University**
**Charles Denk, New Jersey Department of Health**
**Joann Petrini, National Chapter March of Dimes**

***Persistent Cesarean Delivery Risk Among Florida Women:****** ******Who’s Next?***

**Notes:**
Fortunate to have Great collaboration and productive input within DOH, in the state, and across the US.

## Introduction

**Data Source, Florida: Final Birth Data, 1995-2006.**
**Data Source, U.S.: NCHS Final Natality Data, 1995-2004.  ****	****Preliminary Natality Data.**

**0**

**5**

**10**

**15**

**20**

**25**

**30**

**35**

**40**

**1995**

**2006**

**Overall**

**Without Labor**

**With Labor**

*****

**Birth Year**

**Florida**

**U.S.**

**Percentage of Births**

**Cesarean Delivery: ****Florida**** and ****U.S.**** 1995-2006**

**2000**

**Notes:**
Cesarean trends for Florida and US, 1995-2006.
Florida consistently higher than US, and difference growing in recent years.
2004 Florida adopted a revised birth certificate.
Allowed us to look at cesarean by whether labor was attempted.
Cesareans without labor account for almost 2/3 of all cesareans, and are the largest contributor to the overall increase in cesarean delivery.

## Introduction

**Data Source, Florida: Final Birth Data, 1995-2006.**
**Data Source, U.S.: NCHS Final Natality Data, 1995-2004.  ****	****Preliminary Natality Data.**

**0**

**5**

**10**

**15**

**20**

**25**

**30**

**35**

**40**

**1995**

**Overall**

**Without Labor**

**With Labor**

*****

**Birth Year**

**Florida**

**U.S.**

**Percentage of Births**

**Cesarean Delivery: ****Florida**** and ****U.S.**** 1995-2006**

**Range for Florida hospitals with > 2,000 births per year:**
**21 – 60%**
**Data Source: AHCA. Cesarean Rates 1998-2006.**
** ****http://www.floridahealthfinder.gov/researchers/QuickStat/cesarean-buffer.shtml**

**2006**

**2000**

**Notes:**
Florida’s Agency for Health Care administration publishes an annual report on cesarean delivery rates by hospital.
21% is a high risk referral hospital, 60% is not.
So while the state-wide rate in 2006 was about 36%, you can see there was wide variability around this “average”.
The primary aim of the work we are presenting today is where else are we seeing this variability across maternal characteristics, risk groups, and cesarean delivery type.

## Public Health Importance

**Cesarean in FL associated with:**
** ****Increase in preterm birth rate**
** ****Singletons**
** ****1995-2003**
** ****Increased risk of late preterm birth**
** ****Singletons**
** ****2004-2006**
** ****Low-risk cohort**
** ****Session C5, Tomorrow morning**** **

**Notes:**
Understanding the variability was an important step for us, because in Florida we have found that increasing numbers of Cesarean deliveries are associated with over 50% of our increase in preterm birth among singletons, between 1995 and 2003. And in more recent work, which will be presented tomorrow in session XX, we found that cesarean delivery (specifically cesarean without labor) is associated with increased risk of late preterm birth, even among a low risk cohort of women.
Additionally, there is increasing evidence in the literature of adverse outcomes in subsequent pregnancies and increased costs associated with length of stay and rehospitalization.

## Methods: Data

**Data**
** ****Florida 2004***** ****– 2006 birth file**
** ****Study Population**
** ****Resident in-state births**
** ****34-41 weeks**
** ****Singleton gestations**
*** Excludes 1****st**** quarter (old birth cert)**

**Notes:**
We examined Florida birth data, 2004-2006, and initially restricted our analysis to resident in-state births, 34-41 weeks, and singletons. The gestational age restriction was to remove the influence of differential management with regards to cesarean and associated procedures (such as induction) at the tails of the gestational age distribution. Multiple gestations were also excluded because of the strong association with cesarean delivery, and because at only around 3% (which has remained fairly consistent since the late 90s) multiples have not contributed substantially to Florida’s increasing preterm birth rate.

## Methods: Definitions

**Definitions**
** ****Cesarean with labor**
**Attempted vaginal delivery that ends in cesarean **
** ****Check box**
** ****Induction or Augmentation indicated**
** ****Vacuum or Forceps use indicated**
** ****Low-Documented Risk**
**  ****None of 18 medical factors associated with Cesarean**
** ****Not intensive prenatal care usage (GINDEX)**

**Notes:**
Some quick definitions:
Cesarean with labor determined by a check box on the birth certificate, as well as other indications of an attempted vaginal delivery  - such as Induction and vacuum extraction - in conjunction with cesarean delivery. 
(Note: by using induction/augmentation and vacuum/forceps the numbers of cesarean with labor increased 20% beyond check-box alone).
Low-documented risk means that these women had none of 18 medical risk factors – as identified by Dr. Mahan, a leader within the Florida OB community – that are associated with cesarean delivery. Because of concerns about residual undocumented risk, we further removed those women with indications of intensive prenatal care usage.

## Low Documented Risk for Cesarean Delivery

_**None of the following are documented using the birth certificate:**_
-  Hypertension prepregnancy (Chronic)
-  Hypertension gestational (PIH, Preeclampsia)
-  Hypertension - Eclampsia
-  Diabetes Prepregnancy (Diagnosis prior to the pregnancy)
-  Gestational Diabetes (Diagnosis in this pregnancy)
-  Prolonged labor (≥ 20 hours)
-  Moderate/Heavy meconium staining of the amniotic fluid
-  Fetal intolerance of labor (such that in-utero resuscitative measures and/or further fetal assessment and/or operative delivery actions are taken)
-  Clinical Chorioamnionitis diagnosed during labor or maternal temperature >38oC
-  Non-vertex presentation
-  Fetal presentation at birth other than cephalic
-  A birth weight greater than 4,500-g
-  Any of these congenital anomalies:
- 	Anencephaly
-  	Congenital diaphragmatic hernia
-  	Meningomyelocele/Spina bifida
-  	Omphalocele
-  	Cyanotic congenital heart disease
-  	Gastroschisis
-  Modified GINDEX indicates intensive prenatal care use

**Notes:**
List of factors considered in determining if a woman was low-risk for cesarean. The list includes conditions such as hypertension, diabetes, malpresentation...

## Methods: Analysis

**Analysis**
** ****Rates (Cesarean overall)**
** ****Multinomial logistic regression**
** ****Cesarean with labor (Cesarean Labor +)**
** ****Cesarean without labor (Cesarean Labor -)**
** ****STATA 9.2 SE**

**Notes:**
We calculated overall cesarean delivery rates, and then used multinomial logistic regression to determine associaitons with cesarean with labor and cesarean without labor.

## Results: Cesarean Delivery Rates

**Singletons, 34-41 weeks**

**Singleton, 34-41 weeks**

**(n=155,895)**

**Overall (n=479,993)**

**32.5**

**Delivery pay**
**source**

**Medicaid**

**30.1**

** ****Private Insurance**

**35.6**

** ****Self-Pay**

**28.3**

**Race**

** ****White**

**32.8**

**Black**

**31.6**

**Other**

**31.5**

**Ethnicity**

**non-Hispanic**

**31.2**

** ****Mexican**

**27.6**

**Puerto Rican**

**32.9**

** ****Cuban**

**47.0**

**Central / South American**

**36.9**

**Other / Multi-ethnic**

**36.0**

**Age (Years)**

** ****<19**

**21.2**

**19-24**

**26.7**

**25-34**

**34.0**

** ****35+**

**44.3**

**Parity**

** ****1st**

**32.9**

** ****2nd+**

**32.2**

**BMI**

** ****<19.8**

**23.1**

**19.8-26.0**

**29.8**

**26.1-29.0**

**35.6**

** ****29.1+**

**43.0**

**Gestational weight**
**gain**

**Recommended**

**28.0**

**Inadequate**

**27.9**

** ****Excessive**

**37.1**

**Significantly lower than any other category**

**Significantly higher than any other category**

**Notes:**
Here we have rates among singletons deliveries, 34-41 weeks: Pink means significantly higher than any other group. Lavender means significantly lower than any other group.
Highest risk: Private insurance, White race, Hispanic women – with the exception of Mexican women. Among Hispanic women, Cuban women have the highest rates. (Note: best estimates from Cuba are a 23-27% cesarean rate). More mature (older) women, with a significant increase between each increasing age interval. New moms, obese moms, and those that experienced excessive gestational weight gain.

Lowest risk: Self-Pay, Mexican women (Note: From the qualitative work in Pinellas it looks as though a strong desire among Mexican women to get back to work as quickly as possible may be a factor here), experienced moms , and younger women. 

In Florida, and nationally, the percentage of births that are VBAC has declined dramatically over the past decade, and so once a woman delivers by Cesarean, she is almost assuredly going to deliver by Cesarean in subsequent pregnancies. So we wondered how this table would change if we removed previous Cesarean deliveries.

## Results: Cesarean Delivery Rates

**Singleton, 34-41 weeks**

**AND no prior Cesarean**

**(n=155,895)**

**(n=101,912)**

**Overall (****n=479,993****)**

**32.5**

**24.2**

**Delivery pay**** source**

**Medicaid**

**30.1**

**22.1**

** ****Private Insurance**

**35.6**

**27.1**

** ****Self-Pay**

**28.3**

**19.2**

**Race**

**White**

**32.8**

**24.5**

** ****Black**

**31.6**

**22.9**

**Other**

**31.5**

**24.2**

**Ethnicity**

**non-Hispanic**

**31.2**

**23.2**

** ****Mexican**

**27.6**

**18.0**

**Puerto Rican**

**32.9**

**24.1**

** ****Cuban**

**47.0**

**38.8**

**Central / South American**

**36.9**

**27.7**

**Other / Multi-ethnic**

**36.0**

**26.9**

**Age (Years)**

** ****<19**

**21.2**

**19.7**

**19-24**

**26.7**

**20.9**

**25-34**

**34.0**

**24.7**

** ****35+**

**44.3**

**32.2**

**Parity**

** ****1st**

**32.9**

**32.8**

** ****2nd+**

**32.2**

**16.1**

**BMI**

** ****<19.8**

**23.1**

**17.7**

**19.8-26.0**

**29.8**

**22.4**

**26.1-29.0**

**35.6**

**26.1**

** ****29.1+**

**43.0**

**31.9**

**Gestational weight**
** ****gain**

**Recommended**

**28.0**

**20.1**

** ****Inadequate**

**27.9**

**18.9**

** ****Excessive**

**37.1**

**28.9**

**Results: ****Cesarean Delivery Rates**

**AND**** no prior cesarean**

**Significantly lower than any other category**

**Significantly higher than any other category**

**Notes:**
And it did not change much in terms of who had highest or lowest rates. Inadequate gestational weight gain becomes lowest once remove previous Cesareans, and White no longer has the highest rates, while Black women have the lowest rates. 
So now, how does the table change when we further limit to those with low-documented risk for cesarean.

## Results: Cesarean Delivery Rates

**Singleton, 34-41 weeks**

**AND no prior Cesarean**

**AND low documented risk**

**(n=155,895)**

**(n=101,912)**

**(n=53,518)**

**Overall (n=479,993)**

**32.5**

**24.2**

**17.0**

**Delivery pay**
**source**

**Medicaid**

**30.1**

**22.1**

**15.2**

** ****Private Insurance**

**35.6**

**27.1**

**19.6**

** ****Self-Pay**

**28.3**

**19.2**

**13.5**

**Race**

**White**

**32.8**

**24.5**

**17.2**

**Black**

**31.6**

**22.9**

**16.4**

**Other**

**31.5**

**24.2**

**17.2**

**Ethnicity**

**non-Hispanic**

**31.2**

**23.2**

**16.3**

** ****Mexican**

**27.6**

**18.0**

**12.0**

**Puerto Rican**

**32.9**

**24.1**

**17.5**

** ****Cuban**

**47.0**

**38.8**

**28.4**

**Central / South American**

**36.9**

**27.7**

**20.2**

**Other / Multi-ethnic**

**36.0**

**26.9**

**20.1**

**Age (Years)**

** ****<19**

**21.2**

**19.7**

**13.5**

**19-24**

**26.7**

**20.9**

**14.5**

**25-34**

**34.0**

**24.7**

**17.6**

** ****35+**

**44.3**

**32.2**

**23.9**

**Parity**

** ****1st**

**32.9**

**32.8**

**23.8**

** ****2nd+**

**32.2**

**16.1**

**11.5**

**BMI**

** ****<19.8**

**23.1**

**17.7**

**12.0**

**19.8-26.0**

**29.8**

**22.4**

**16.0**

**26.1-29.0**

**35.6**

**26.1**

**18.9**

** ****29.1+**

**43.0**

**31.9**

**23.4**

**Gestational weight**
** ****gain**

**Recommended**

**28.0**

**20.1**

**14.1**

** ****Inadequate**

**27.9**

**18.9**

**12.7**

** ****Excessive**

**37.1**

**28.9**

**21.0**

**Results: ****Cesarean Delivery Rates**

**Significantly lower than any other category**

**Significantly higher than any other category**

**AND**** low-documented risk**

**Notes:**
Again – no real change, except race differences wash out. But we know that there is interplay among these characteristics and their association with delivery route. Using multinomial logistic regression, we can look at the adjusted association of these characteristics with Cesarean delivery with labor and Cesarean delivery without trial of labor.

## Results: Regression

**Adjusted Odds Ratio (AOR) of Cesarean Delivery Among ****Florida**** Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006.**** **

_**Data Source:**_
**FL 2004-2006,**
**Final Birth File.**
_**Adjusted for:**_** **
**Pay source, Adequacy of prenatal care, Infertility treatment, Parity, BMI, Gestational weight gain, Birth year, Birth day of week.**

**Notes:**
Here is the first of 3 tables with the results of the regression among the lowest risk cohort of women. We expanded characteristics for these models beyond those shown in the rates tables. It can be seen than risk – increased and decreased – tends to persist across Cesarean delivery types. Increased for Black women, Hispanic women – except for the Mexican women, and older women. 

## Results: Regression

**Adjusted Odds Ratio (AOR) of Cesarean Delivery Among ****Florida**** Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006.**** **

_**Data Source:**_
**FL 2004-2006,**
**Final Birth File.**
_**Adjusted for:**_** **
**Race, Ethnicity, Age, Marital Status, Smoking, Maternal Education, Birth year, Birth day of week.**

**Notes:**
Again, we further see a general consistency in risk across Cesarean delivery types. Decreased risk among multiparous, underweight, and inadequate gestational weight gain women and increased risk among heavier women, and those with excessive gestational weight gain.

## Results: Regression

**Adjusted Odds Ratio (AOR) of Cesarean Delivery Among ****Florida**** Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006.**** **

_**Data Source:**_
**FL 2004-2006,**
**Final Birth File.**
_**Adjusted for:**_** **
**Race, Ethnicity, Age, Marital Status, Smoking, Maternal Education,** **Pay source, Adequacy of prenatal care, Infertility treatment, Parity, BMI, Gestational weight gain.**

**Notes:**
And the last regression table. Increased risk among birth year and birth day of the week. Of note is that Even though all days of the week

## Limitations

**Limited to birth certificate data**
** ****Misclassification**
** ****Gestational age**
** ****Delivery route**
** ****Medical Risk Factors**
** ****Labor**
** ****Labor categorized as no labor**
** ****Differentiate emergency from scheduled Cesareans**

**Notes:**
We have those limitations commonly cited with using birth certificate data, including concerns about misclassification due to incomplete recording. Gestational age is based on LMP, which while the current recommended method for determining gestational age, has limitations. Delivery route is generally considered reliable from the birth cert, and comparisons to FL AHCA data confirms this. There is variablility in completeness of medical risk factor on the birth certificate, and we handled this by additionally removing those women who we indication of intensive prenatal care usage. We cannot currently say how effective this was at removing residual medical risk associated with Cesarean delivery. And with Labor, there is the potential that women who labored prior to Cesarean were misclassified as not laboring, and within those that did not labor, we could not differentiate emergency from planned cesareans. 

## Summary

**Persistent variability in Cesarean delivery:**
** ****Across characteristics of women**
** ****Hispanic**
** ****Older**
** ****Heavier**
** ****Across risk subsets of women**
** ****Singletons**
** ****AND**** No previous cesarean**
** ****AND**** Low-documented risk**
** ****Across Cesarean delivery types**
** ****With labor**
** ****Without labor**

**Notes:**
To summarize: We found persistent variability in Cesarean delivery, across Characteristics of women, risk subsets of women, and cesarean delivery types.

## Implications

**Informative to explore subgroups**
** ****Hispanic mix may be why FL Hispanics have highest rates, while nationally it is non-Hispanic Black women**
**Gaps in intrapartum surveillance**
** ****What medical and social risk factors are we missing?**

**Notes:**
We are a bit spoiled in FL by the large number of annual births, which allows us to richly explore the birth data. Finding that a subset (Mexican) has the lowest rates within the broad grouping of Hispanic women, which had the highest rates, may help explain the surprising finding that Hispanic women in Florida had the highest Cesarean delivery rates, while nationally it is non-Hispanic Black women. Most importantly our findings highlight a gap in intrapartum surveillance. We cannot explain the disparities in Cesarean delivery, and are left to speculate on what uncaptured medical and social factors might be contributing.  

## Current Activities

**March of Dimes Preterm Birth Prevention Statewide Workgroup**
**Florida Obstetric and Gynecologic Society (FOGS) – Dept. of Health Informal Study Group**
**Review evidence-base**
**Develop recommendations on next steps**
**2 Meetings completed!**
**Qualitative Cesarean focus groups (Healthy Start Coalition of Pinellas)**
**Awaiting (and planning for) PRAMS Phase 6**
**New Standard questions about why and when of Cesarean delivery**

**Notes:**
We are excited to be able to put this slide up. Moving data to action.
In Florida, The March of Dimes Preterm Birth Prevention workgroup has made the association of cesarean delivery and preterm birth a priority.
We are also in the process of conducting an informal study group consisting of FOGS and DOH representatives, to review the evidence and develop recommendations on next steps. Engaging FL OB community is key to understanding and impacting Cesarean delivery. We have now completed two meetings of this study group, reviewing the data that will allow progress toward next steps.
We have been consulting with Pinellas county who has begun focus groups among women in their county who delivered by cesarean. Initially they have focused on Hispanic women, but they are now looking to expand their work. 
Last – we are planning for PRAMS Phase 6, where a new set of Standard questions that offer the opportunity to fill some of the intrapartum surveillance gaps that currently exist.

## End

**dave_goodman@doh.state.fl.us**

## Day of the Week: Delivery Route

- 20

- 40

- 60

- 80

- 100

- 120

- 140

**Index of Occurrence**

- Sun

- Mon

- Tue

- Wed

- Thu

- Fri

- Sat

**Day of Week**

**Index of Occurrence of Delivery Route: ****Florida**** 2004-2006**
**Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical Induction (N=263,326)**

**Vaginal**

**Cesarean with labor**

**Cesarean without labor**

- Data Source: 2004-2006, Final Birth File.

**Notes:**
Index of occurrence of delivery route:
	Supports that Cesarean without labor is not largely influenced by emergency Cesareans.
	Supports active (surgical) management.

## Hour of Day: Delivery Route

- 0

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- 8

- 9

- 10

- 11

- 12

- 13

- 14

- 15

- 16

- 17

- 18

- 19

- 20

- 21

- 22

- 23

**Hour of Day: ****Delivery Route**

**Index of Occurrence of Delivery Route: ****Florida**** 2004-2006**
**Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical Induction (N=260,023)**

**Index of Occurrence**

**Hour of Day**

- 0

- 100

- 200

- 300

**Vaginal**

**Cesarean with labor**

**Cesarean without labor**

- Data Source: 2004-2006, Final Birth File.

**Notes:**
Same strong patterns by hour of day.