This report describes the development of a measure of low-risk cesarean delivery by the Society for Maternal-Fetal Medicine (SMFM). Safely lowering the cesarean delivery rate is a priority for maternity care clinicians and health care delivery systems. Therefore, hospital quality assurance programs are increasingly tracking cesarean delivery rates among low-risk pregnancies. Two commonly used definitions of “low risk” are available, the Joint Commission (JC) and the Agency for Healthcare Research and Quality (AHRQ) measures, but these measures are not clinically comprehensive. We sought to refine the definition of the low-risk cesarean delivery rate to enhance the validity of the metric for quality measurement. We created this refined definition–called the SMFM definition–and compared it to the JC and AHRQ measures using claims-based data from the 2011 Nationwide Inpatient Sample of >863,000 births in 612 hospitals. Using these definitions, we calculated means and interquartile ranges (25th-75th percentile range) for hospital low-risk cesarean delivery rates, stratified by hospital size, teaching status, urban/rural location, and payer mix. Across all hospitals, the mean low-risk cesarean delivery rate was lowest for the SMFM definition (12.65%), but not substantially different from the JC and AHRQ measures (13.12% and 13.29%, respectively). We empirically examined the SMFM definition to ensure its validity and utility. This refined definition performs similarly to existing measures and has the added advantage of clinical perspective, enhanced face validity, and ease of use.
Members of the Society for Maternal-Fetal Medicine Health Policy Committee: Joanne Armstrong, Sean C. Blackwell, Suneet P. Chauhan, Rebekah Gee, William Grobman, James Keller, Judette Louis, Kate Menard, Dan O’Keeffe, Carolina Reyes, George R. Saade, Kathryn Schubert, Cathy Spong, Sindhu Srinivas, and Thomas Westover.
Measurement of the low-risk cesarean delivery rate
Lowering the low-risk cesarean delivery rate has been a recent public health focus. Two risk-adjusted or low-risk cesarean delivery rate measures developed by the Joint Commission (JC) and the Agency for Healthcare Research and Quality (AHRQ) are currently used for hospital reporting. Both define “low risk” as term, singleton, live birth deliveries in the vertex presentation. The JC measure applies only to nulliparous patients. The AHRQ measure captures women with no prior cesareans. Both measures identify additional medical factors that classify the delivery as high risk for cesarean delivery and thus exclude those deliveries from measurement ( Table 1 ). The medical factors identified for exclusion are similar, but not identical, between the 2 measures. Further, these lists are not exhaustive, omitting some well-accepted contraindications to vaginal birth such as placenta previa as well as conditions that are likely to lead to cesarean delivery such as HIV infection. Although these risk factors have low prevalence at a population level, if they are not excluded in a low-risk cesarean delivery rate definition, the face validity of the measure for practicing physicians and hospitals is decreased. Further, this creates skepticism about the measure, particularly among hospitals that disproportionately care for women with some of these conditions. More concerning from a policy perspective is the potential of limiting access to care to women with high-risk conditions that are not excluded from the low-risk cesarean delivery definition as a strategy to reduce the low-risk cesarean delivery rate. An additional challenge with the JC measure is that it is labor intensive and requires hospital resources for chart abstraction.
| ICD9 Diagnosis Code | ICD9 Diagnosis Code Short Description | Risk Factor Classification | SMFM | JC | AHRQ |
|---|---|---|---|---|---|
| 042 | HUMAN IMMUNO VIRUS DIS | Maternal factors | x | ||
| 641.01 | PLACENTA PREVIA-DELIVER | Maternal factors | x | ||
| 641.11 | PLACENTA PREV HEM-DELIV | Maternal factors | x | ||
| 642.6 | ECLAMPSIA | Maternal factors | x | ||
| 642.60 | ECLAMPSIA-UNSPECIFIED | Maternal factors | x | ||
| 642.61 | ECLAMPSIA-DELIVERED | Maternal factors | x | ||
| 642.62 | ECLAMPSIA-DELIV W P/P | Maternal factors | x | ||
| 642.63 | ECLAMPSIA-ANTEPARTUM | Maternal factors | x | ||
| 644.2 | EARLY ONSET OF DELIVERY | Preterm birth | x | ||
| 644.20 | EARLY ONSET DELIV-UNSPEC | Preterm birth | x | X | |
| 644.21 | EARLY ONSET DELIVERY-DEL | Preterm birth | x | x | x |
| 646 | PAPYRACEOUS FETUS | Stillborn | x | ||
| 646.0 | PAPYRACEOUS FETUS | Stillborn | x | ||
| 646.00 | PAPYRACEOUS FETUS-UNSPEC | Stillborn | x | ||
| 646.01 | PAPYRACEOUS FETUS-DELIV | Stillborn | x | ||
| 646.03 | PAPYRACEOUS FET-ANTEPAR | Stillborn | x | ||
| 648.51 | CONGEN CV DIS-DELIVERED | Maternal factors | x | ||
| 648.52 | CONGEN CV DIS-DEL W P/P | Maternal factors | x | ||
| 648.53 | CONGEN CV DIS-ANTEPARTUM | Maternal factors | x | ||
| 648.54 | CONGEN CV DIS-POSTPARTUM | Maternal factors | x | ||
| 648.6 | OTHER CARDIOVASCULAR DISEASE | Maternal factors | x | ||
| 648.60 | CV DIS NEC PREG-UNSPEC | Maternal factors | x | ||
| 648.61 | CV DIS NEC PREG-DELIVER | Maternal factors | x | ||
| 648.62 | CV DIS NEC-DELIVER W P/P | Maternal factors | x | ||
| 648.63 | CV DIS NEC-ANTEPARTUM | Maternal factors | x | ||
| 648.64 | CV DIS NEC-POSTPARTUM | Maternal factors | x | ||
| 651 | TWIN PREGNANCY | Multiple gestation | x | ||
| 651.0 | TWIN PREGNANCY | Multiple gestation | x | ||
| 651.00 | TWIN PREGNANCY-UNSPEC | Multiple gestation | x | x | |
| 651.01 | TWIN PREGNANCY-DELIVERED | Multiple gestation | x | x | x |
| 651.03 | TWIN PREGNANCY-ANTEPART | Multiple gestation | x | x | |
| 651.1 | TRIPLET PREGNANCY | Multiple gestation | x | ||
| 651.10 | TRIPLET PREGNANCY-UNSPEC | Multiple gestation | x | x | |
| 651.11 | TRIPLET PREGNANCY-DELIV | Multiple gestation | x | x | x |
| 651.13 | TRIPLET PREG-ANTEPARTUM | Multiple gestation | x | x | |
| 651.2 | QUADRUPLET PREGNANCY | Multiple gestation | x | ||
| 651.20 | QUADRUPLET PREG-UNSPEC | Multiple gestation | x | x | |
| 651.21 | QUADRUPLET PREG-DELIVER | Multiple gestation | x | x | x |
| 651.23 | QUADRUPLET PREG-ANTEPART | Multiple gestation | x | x | |
| 651.3 | TWIN PREGNANCY WITH FETAL LO | Multiple gestation | x | ||
| 651.30 | TWINS W FETAL LOSS-UNSP | Multiple gestation | x | x | |
| 651.31 | TWINS W FETAL LOSS-DEL | Multiple gestation | x | x | x |
| 651.33 | TWINS W FETAL LOSS-ANTE | Multiple gestation | x | x | |
| 651.4 | TRIPLET PREGNANCY WITH FETAL | Multiple gestation | x | ||
| 651.40 | TRIPLETS W FET LOSS-UNSP | Multiple gestation | x | x | |
| 651.41 | TRIPLETS W FET LOSS-DEL | Multiple gestation | x | x | x |
| 651.43 | TRIPLETS W FET LOSS-ANTE | Multiple gestation | x | x | |
| 651.5 | QUADRUPLET PREGNANCY WITH FE | Multiple gestation | x | ||
| 651.50 | QUADS W FETAL LOSS-UNSP | Multiple gestation | x | x | |
| 651.51 | QUADS W FETAL LOSS-DEL | Multiple gestation | x | x | x |
| 651.53 | QUADS W FETAL LOSS-ANTE | Multiple gestation | x | x | |
| 651.6 | OTHER MULTIPLE PREGNANCY WIT | Multiple gestation | x | ||
| 651.60 | MULT GES W FET LOSS-UNSP | Multiple gestation | x | x | |
| 651.61 | MULT GES W FET LOSS-DEL | Multiple gestation | x | x | x |
| 651.63 | MULT GES W FET LOSS-ANTE | Multiple gestation | x | x | |
| 651.7 | MULTIPLE GESTATION | Multiple gestation | x | ||
| 651.70 | MUL GEST-FET REDUCT UNSP | Multiple gestation | x | ||
| 651.71 | MULT GEST-FET REDUCT DEL | Multiple gestation | x | ||
| 651.73 | MUL GEST-FET REDUCT ANTE | Multiple gestation | x | ||
| 651.8 | OTHER SPECIFIED MULTIPLE GES | Multiple gestation | x | ||
| 651.80 | MULTI GESTAT NEC-UNSPEC | Multiple gestation | x | x | |
| 651.81 | MULTI GESTAT NEC-DELIVER | Multiple gestation | x | x | x |
| 651.83 | MULTI GEST NEC-ANTEPART | Multiple gestation | x | x | |
| 651.9 | UNSPECIFIED MULTIPLE GESTATI | Multiple gestation | x | ||
| 651.90 | MULTI GESTAT NOS-UNSPEC | Multiple gestation | x | x | |
| 651.91 | MULT GESTATION NOS-DELIV | Multiple gestation | x | x | x |
| 651.93 | MULTI GEST NOS-ANTEPART | Multiple gestation | x | x | |
| 652.20 | BREECH PRESENTAT-UNSPEC | Malpresentation | x | ||
| 652.21 | BREECH PRESENTAT-DELIVER | Malpresentation | x | x | x |
| 652.23 | BREECH PRESENT-ANTEPART | Malpresentation | x | ||
| 652.30 | TRANSV/OBLIQ LIE-UNSPEC | Malpresentation | x | ||
| 652.31 | TRANSVER/OBLIQ LIE-DELIV | Malpresentation | x | x | x |
| 652.33 | TRANSV/OBLIQ LIE-ANTEPAR | Malpresentation | x | ||
| 652.40 | FACE/BROW PRESENT-UNSPEC | Malpresentation | x | ||
| 652.41 | FACE/BROW PRESENT-DELIV | Malpresentation | x | x | x |
| 652.43 | FACE/BROW PRES-ANTEPART | Malpresentation | x | ||
| 652.6 | MULTIPLE GESTATION, MALPRESE | Multiple gestation | x | ||
| 652.60 | MULT GEST MALPRESEN-UNSP | Multiple gestation | x | x | |
| 652.61 | MULT GEST MALPRES-DELIV | Multiple gestation | x | x | x |
| 652.63 | MULT GES MALPRES-ANTEPAR | Multiple gestation | x | x | |
| 652.70 | PROLAPSED ARM-UNSPEC | Malpresentation | x | ||
| 652.71 | PROLAPSED ARM-DELIVERED | Malpresentation | x | ||
| 652.81 | MALPOSITION NEC-DELIVER | Malpresentation | x | ||
| 653.6 | HYDROCEPHALIC FETUS CAUSING | Fetal factors | x | ||
| 653.60 | HYDROCEPHAL FETUS-UNSPEC | Fetal factors | x | ||
| 653.61 | HYDROCEPH FETUS-DELIVER | Fetal factors | x | ||
| 653.63 | HYDROCEPH FETUS-ANTEPART | Fetal factors | x | ||
| 653.71 | OTH ABN FET DISPRO-DELIV | Fetal factors | x | ||
| 654.2 | UTERINE SCAR FROM PREVIOUS S | Uterine/placental factors | x | ||
| 654.20 | PREV C-DELIVERY UNSPEC | Uterine/placental factors | x | x | |
| 654.21 | PREV C-DELIVERY-DELIVRD | Uterine/placental factors | x | x | x |
| 654.23 | PREV C-DELIVERY-ANTEPART | Uterine/placental factors | x | x | |
| 654.3 | RETROVERTED AND INCARCERATED | Uterine/placental factors | x | ||
| 654.30 | RETROVERT UTERUS-UNSPEC | Uterine/placental factors | x | ||
| 654.31 | RETROVERT UTERUS-DELIVER | Uterine/placental factors | x | ||
| 654.32 | RETROVERT UTER-DEL W P/P | Uterine/placental factors | x | ||
| 654.33 | RETROVERT UTER-ANTEPART | Uterine/placental factors | x | ||
| 654.34 | RETROVERT UTER-POSTPART | Uterine/placental factors | x | ||
| 655.01 | FETAL CNS MALFORM-DELIV | Fetal factors | x | ||
| 656.4 | INTRAUTERINE DEATH COMPLICAT | Stillborn | x | ||
| 656.40 | INTRAUTERINE DEATH-UNSP | Stillborn | x | x | x |
| 656.41 | INTRAUTER DEATH-DELIVER | Stillborn | x | x | x |
| 656.43 | INTRAUTER DEATH-ANTEPART | Stillborn | x | ||
| 660.3 | DEEP TRANSVERSE ARREST, PERS | Malpresentation | x | ||
| 660.30 | DEEP TRANS ARR AND PERSIST OP-UNSP | Malpresentation | x | ||
| 660.31 | DEEP TRANS ARR AND PERSIST OP -DELIV | Malpresentation | x | ||
| 660.5 | LOCKED TWINS COMPLICATING PR | Multiple gestation | x | ||
| 660.50 | LOCKED TWINS-UNSPECIFIED | Multiple gestation | x | x | |
| 660.51 | LOCKED TWINS-DELIVERED | Multiple gestation | x | x | x |
| 660.53 | LOCKED TWINS-ANTEPARTUM | Multiple gestation | x | x | |
| 660.7 | FAILED FORCEPS OR VACUUM EXT | Conduct of labor | x | ||
| 660.70 | FAILED FORCEP NOS-UNSPEC | Conduct of labor | x | ||
| 660.71 | FAILED FORCEPS NOS-DELIV | Conduct of labor | x | ||
| 660.73 | FAIL FORCEPS NOS-ANTEPAR | Conduct of labor | x | ||
| 662.3 | DELAYED DELIVERY SECOND TWIN | Multiple gestation | x | ||
| 662.30 | DELAY DEL 2ND TWIN-UNSP | Multiple gestation | x | x | |
| 662.31 | DELAY DEL 2ND TWIN-DELIV | Multiple gestation | x | x | x |
| 662.33 | DELAY DEL 2 TWIN-ANTEPAR | Multiple gestation | x | x | |
| 663 | PROLAPSE OF UMBILICAL CORD C | Uterine/placental factors | x | ||
| 663.0 | PROLAPSE OF UMBILICAL CORD C | Uterine/placental factors | x | ||
| 663.00 | CORD PROLAPSE-UNSPEC | Uterine/placental factors | x | ||
| 663.01 | CORD PROLAPSE-DELIVERED | Uterine/placental factors | x | ||
| 663.03 | CORD PROLAPSE-ANTEPARTUM | Uterine/placental factors | x | ||
| 663.5 | VASA PREVIA COMPLICATING PRE | Uterine/placental factors | x | ||
| 663.50 | VASA PREVIA-UNSPECIFIED | Uterine/placental factors | x | ||
| 663.51 | VASA PREVIA-DELIVERED | Uterine/placental factors | x | ||
| 663.53 | VASA PREVIA-ANTEPARTUM | Uterine/placental factors | x | ||
| 665 | RUPTURE UTERUS BEFORE ONSET | Uterine/placental factors | x | ||
| 665.0 | RUPTURE UTERUS BEFORE ONSET | Uterine/placental factors | x | ||
| 665.00 | PRELABOR RUPT UTER-UNSP | Uterine/placental factors | x | ||
| 665.01 | PRELABOR RUPT UTERUS-DEL | Uterine/placental factors | x | ||
| 665.03 | PRELAB RUPT UTER-ANTEPAR | Uterine/placental factors | x | ||
| 665.1 | RUPTURE UTERUS DURING/AFTER | Uterine/placental factors | x | ||
| 665.10 | RUPTURE UTERUS NOS-UNSP | Uterine/placental factors | x | ||
| 665.11 | RUPTURE UTERUS NOS-DELIV | Uterine/placental factors | x | ||
| 665.12 | RUPTURE UTERUS DURING/AFTER | Uterine/placental factors | x | ||
| 665.14 | RUPTURE UTERUS DURING/AFTER | Uterine/placental factors | x | ||
| 669.6 | BREECH EXTRACTION WITHOUT ME | Malpresentation | x | ||
| 669.60 | BREECH EXTR NOS-UNSPEC | Malpresentation | x | x | |
| 669.61 | BREECH EXTR NOS-DELIVER | Malpresentation | x | x | x |
| 678.10 | FETAL CONJOIN TWINS-UNSP | Fetal factors | x | x | |
| 678.11 | FETAL CONJOIN TWINS-DEL | Fetal factors | x | x | |
| 678.13 | FETAL CONJOIN TWINS-ANTE | Fetal factors | x | x | |
| 761.5 | MULT PREGNANCY AFF NB | Multiple gestation | x | x | x |
| V08 | ASYMP HIV INFECTN STATUS | Maternal factors | x | ||
| V27.1 | DELIVER-SINGLE STILLBORN | Stillborn | x | x | x |
| V27.2 | DELIVER-TWINS, BOTH LIVE | Multiple gestation | x | x | x |
| V27.3 | DEL-TWINS, 1 NB, 1 SB | Stillborn | x | x | x |
| V27.4 | DELIVER-TWINS, BOTH SB | Stillborn | x | x | x |
| V27.5 | DEL-MULT BIRTH, ALL LIVE | Multiple gestation | x | x | x |
| V27.6 | DEL-MULT BRTH, SOME LIVE | Multiple gestation | x | x | x |
| V27.7 | DEL-MULT BIRTH, ALL SB | Stillborn | x | x | x |
| V91.00 | TWIN GEST-PLAC/SAC NOS | Multiple gestation | x | ||
| V91.01 | TWIN GEST-MONOCHR/MONOAM | Multiple gestation | x | ||
| V91.02 | TWIN GEST-MONOCHR/DIAMNI | Multiple gestation | x | ||
| V91.03 | TWIN GEST-DICH/DIAMNIOTC | Multiple gestation | x | ||
| V91.09 | TWIN GEST-PLAC/SAC UNDET | Multiple gestation | x | ||
| V91.10 | TRIPL GEST-PLAC/SAC NOS | Multiple gestation | x | ||
| V91.11 | TRIPLET GEST 2+ MONOCHOR | Multiple gestation | x | ||
| V91.12 | TRIPLET GEST 2+ MONOAMN | Multiple gestation | x | ||
| V91.19 | TRIPL GEST-PLAC/SAC UND | Multiple gestation | x | ||
| V91.20 | QUAD GEST-PLAC/SAC NOS | Multiple gestation | x | ||
| V91.21 | QUAD GEST 2+ MONOCHORION | Multiple gestation | x | ||
| V91.22 | QUAD GEST 2+ MONOAMNIOTC | Multiple gestation | x | ||
| V91.29 | QUAD GEST-PLAC/SAC UNDET | Multiple gestation | x | ||
| V91.90 | MULT GEST-PLAC/SAC NOS | Multiple gestation | x | ||
| V91.91 | MULT GEST 2+ MONOCHR NEC | Multiple gestation | x | ||
| V91.92 | MULT GEST 2+ MONOAMN NEC | Multiple gestation | x | ||
| V91.99 | MULT GEST-PLAC/SAC UNDET | Multiple gestation | x |
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