{
  "abstract": "Importance: The Society for Maternal-Fetal Medicine (SMFM) low-risk cesarean delivery metric aims to improve comparability, but the extent to which additional patient-level adjustment and reliability profiling alter hospital rankings is not well characterized.\n\nObjectives: To evaluate how hospital cesarean delivery rankings differ across overall, SMFM-defined low-risk, and reliability-adjusted low-risk approaches, and to identify hospital characteristics associated with reliability-adjusted low-risk rates.\n\nDesign, Setting, and Participants: This cross-sectional study used data from the 2022 National Inpatient Sample, a nationally representative all-payer database, on individuals aged 11 to 55 years who were hospitalized for childbirth. Data were analyzed from October 2025 through June 2026.\n\nMain Outcomes and Measures: Hospital cesarean delivery rates and rankings based on overall births, SMFM low-risk births (unadjusted), and empirical bayesian reliability-adjusted SMFM low-risk rates (mixed-effects logistic regression adjusting for age and obstetric comorbidities). Concordance was summarized by quartile cross-classification. Hospitals were classified as as-expected, lower-than-expected, or higher-than-expected on the basis of the 95% credible interval for the reliability-adjusted rate relative to the overall mean, and a hospital-level multivariable regression assessed characteristics associated with that rate.\n\nResults: Of the 330 977 SMFM low-risk deliveries (mean [SD] maternal age, 29.0 [5.7] years) across 1231 hospitals, 45 471 (13.7%) were cesarean. Mean (SD) hospital cesarean delivery rates were 32.1% (5.4%) for overall cesarean delivery, 13.5% (4.2%) for SMFM low-risk cesarean delivery, and 10.4% (2.4%) for reliability-adjusted SMFM low-risk cesarean delivery. Quartile concordance between overall and unadjusted SMFM low-risk rankings was modest (61.7% agreement in the lowest quartile), whereas concordance between SMFM low-risk and reliability-adjusted rankings was higher (85.7% agreement in the lowest quartile). Based on 95% credible intervals, 1024 hospitals (83.2%) were classified as having as-expected rates of cesarean delivery, 81 (6.6%) as having lower-than-expected rates of cesarean delivery, and 126 (10.2%) as having higher-than-expected rates of cesarean delivery. In multivariable analysis, Midwestern (β = −1.13 percentage points; 95% CI, −1.56 to −0.70 percentage points) and Western (β = −1.26 percentage points; 95% CI, −1.68 to −0.83 percentage points) hospitals had lower reliability-adjusted rates than Northeastern hospitals.\n\nConclusions and Relevance: In this cross-sectional study of US hospitals, cesarean delivery rankings differed substantially between overall and SMFM low-risk denominators, highlighting limitations of overall rates for accountability. The high concordance between unadjusted and reliability-adjusted rankings suggests that the SMFM low-risk metric already captures most of the between-hospital signal. US region was the strongest correlate of reliability-adjusted rates.",
  "abstract_shown": true,
  "affiliations": [
    "EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia",
    "EVMS Center for Maternal and Child Health Equity and Advocacy, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia",
    "Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 3,
  "authors": [
    {
      "affs": [
        0,
        1
      ],
      "name": "Tetsuya Kawakita"
    },
    {
      "affs": [
        2
      ],
      "name": "Regan N. Theiler"
    },
    {
      "affs": [
        0
      ],
      "name": "George Saade"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/2ysg785y8ge1n.bib",
  "cited_by": 0,
  "doi": "10.1001/jamanetworkopen.2026.37167",
  "fulltext_url": null,
  "id": "2ysg785y8ge1n",
  "issns": [
    "2574-3805"
  ],
  "landing_url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854695",
  "language": null,
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "journal",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "2729|Maternal and Perinatal Health Interventions"
    ]
  ],
  "openalex": "W7215120451",
  "pdf_url": null,
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-01",
  "publisher": "American Medical Association (AMA)",
  "ris": "https://research.draconitic.com/paper/2ysg785y8ge1n.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:19:46Z",
      "native_id": "10.1001/jamanetworkopen.2026.37167",
      "source": "crossref",
      "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854695"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2729|Maternal and Perinatal Health Interventions",
      "subfield": "reproductive-child"
    }
  ],
  "title": "Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics",
  "title_text": "Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:19:46Z",
  "url": "https://research.draconitic.com/paper/2ysg785y8ge1n",
  "venue": "JAMA Network Open",
  "versions": []
}