Assessing regional variation in cesarean birth and vaginal birth after cesarean rates in a major metropolitan area: improving health service delivery

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Abstract
Objective: To determine variation in utilization of cesarean delivery and vaginal birth after cesarean delivery (VBAC) by physicians and within hospitals as part of a regional assessment of care designed to improve overall quality of health service delivery. Methods: Using risk strata designed to classify patients into high and low risk for cesarean birth, 26,358 consecutive deliveries between July 1997 and June 1998 were analyzed for total deliveries, cesarean birth, and vaginal birth after cesarean delivery rates from data representing 285 physicians in all 22 Pittsburgh metropolitan statistical-area hospitals. Results: The overall hospital cesarean birth and vaginal birth after cesarean delivery rates were 19% (range, 13–25) [N = 5,017] and 40.5% (range, 18–60) [N = 1,166], respectively, with significant risk-stratified variation by physician. Low-risk and high-risk rates ranged from 8.5% to 19.5% and from 53% to 92%, respectively. Of all repeat cesarean births, 29% (1,437) were performed on patients stratified at low risk. Conclusions: The significant variation among physicians for cesarean birth and VBAC rates suggests that decision making by physicians providing obstetric care is a major contributor to overall rates. Low VBAC rates, combined with high numbers of low-risk repeat cesarean deliveries, provide the best opportunity to modify practice patterns.

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