The hospital matters: The impact of level of care on cesarean delivery rates in pregnancies complicated by preeclampsia

OBJECTIVE: To examine the cesarean delivery rates in pregnancies complicated by preeclampsia in hospitals providing differing level of NICU services. STUDY DESIGN: Maternal-infant hospital discharge data from 1999- 2009 was examined using the California Office of Statewide Hospital Planning and Development database. Women with prior cesarean, previa, or malpresentation were excluded. Cesarean rates for pregnancies complicated by preeclampsia with severe features were calculated, as a function of NICU level (3a, 3b, 3c+). Logistic regression was used to determine odds ratios (OR) and 95% confidence intervals (CI) for cesarean delivery with level 3c+ hospitals serving as the reference group. RESULTS: There were 231,696 subjects identified who had preeclampsia and who were eligible for a trial of labor. A significant reduction in cesarean was noted with increasing level of NICU care (P<0.005): 37.5% (n=9,635) in level 3a, 35.6% (n=20,005) in level 3b, and 35.1% (n=25,114) in level 3c+ hospitals. In adjusted analyses, the odds of cesarean remained statistically higher among women delivering in 3a and 3b hospitals vs. 3c+ hospitals (Table 1). At term (≥37 weeks), the odds of cesarean was 20% higher among deliveries in 3a hospitals (aOR 1.20, 95% CI=1.16-1.25) as compared to hospitals with the highest level of NICU care (3c+). CONCLUSION: Cesarean rates for subjects with preeclampsia are higher in hospitals with lower level NICUs. The route of delivery can be influenced by hospital culture and level of care. This analysis raises an important question regarding the ability of hospitals to provide the risk-appropriate level of maternal care. While hospitals may open NICUs to reduce the number of transfers, they should also be cognizant of the need for appropriately matched higher-level maternal care. The root causes behind these differences and their impact on outcomes should be further studied. (Table presented).