Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics
- 1EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia
- 2EVMS 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
- 3Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
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.
Objectives: 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.
Design, 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.
Main 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.
Results: 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.
Conclusions 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.
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BibTeX
@article{kawakita2026hospital,
title = {{Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics}},
author = {Tetsuya Kawakita and Regan N. Theiler and George Saade},
journal = {JAMA Network Open},
year = {2026},
month = oct,
doi = {10.1001/jamanetworkopen.2026.37167},
url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854695},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics
AU - Tetsuya Kawakita
AU - Regan N. Theiler
AU - George Saade
PY - 2026
DA - 2026/10/01
JO - JAMA Network Open
DO - 10.1001/jamanetworkopen.2026.37167
UR - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854695
AB - 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. Objectives: 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. Design, 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. Main 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. Results: 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. Conclusions 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.
SN - 2574-3805
ER -