Women's Health Issues 26-3 (2016) 329335

www.whijournal.com

Reproductive Health

Race, Insurance Status, and Nulliparous, Term, Singleton, Vertex

Cesarean Indication: A Case Study of a New England Tertiary
Hospital
Theresa Morris, PhD a,*, Olivia Meredith, BA b, Mia Schulman, BA c,
Christine H. Morton, PhD d
a
Department of Sociology, Texas A&M University, College Station, Texas
b
Student Outreach and Support Department, MIT, Cambridge, Massachusetts
c
Tiger Foundation, New York, New York
d
Department of Pediatrics, California Maternal Quality Care Collaborative at Stanford University, Palo Alto, California

Article history: Received 22 May 2015; Received in revised form 11 February 2016; Accepted 16 February 2016

a b s t r a c t
Introduction: The current U.S. cesarean section rate (32.2%) is recognized as too high in light of its negative health
impacts on women and infants. Efforts are underway in several states and individual hospitals to lower the rate of
cesarean section among low-risk women, dened as nulliparous (rst birth), term (
37 weeks gestation), singleton (one
baby), vertex (head down presentation; NTSV).
Objectives: We conducted a case study of one hospitals experience with NTSV cesarean sections to see whether race and
insurance status affect the probability of cesarean indication. Many cesarean indications are ambiguous, and biases may
seep into decisions with ambiguous diagnoses.
Methods: We conducted a retrospective chart review of women who had NTSV cesarean sections at a tertiary care
hospital in an urban New England city between June 2013 and November 2013. We analyzed the data using multinomial
logistic regression to examine the marginal effect of race and health insurance status on the predicted probability for
NTSV cesarean indication.
Results: We nd that Black and Hispanic women have a lower predicted probability of having a cesarean section for
cephalopelvic disproportion than do White women and that women with private health insurance have a lower pre-
dicted probability of having a cesarean section for nonreassuring fetal heart rate and for a clinical indication than do
women without private health insurance.
Discussion: We suggest biases may seep into clinicians decisions to perform an NTSV cesarean section. Hospital quality
improvement efforts are aided by an examination of sociodemographic factors that inuence clinician decision making
in the specic hospital being studied.
2016 Jacobs Institute of Womens Health. Published by Elsevier Inc.

Since 1970, the U.S. cesarean delivery rate has increased by
almost 500%. In 2014, 32.2% of women gave birth by cesarean
(Hamilton, Martin, Osterman, & Curtin, 2015). Cesarean sections
The authors thank Adam Grossberg for advice on the analysis and Jennifer
Moller for serving as the hospital-employee PI on our hospital IRB application.
An earlier version of this paper was presented at the 2014 Eastern Sociological
Society meetings.
* Correspondence to: Theresa Morris, PhD, Department of Sociology, Texas
A&M University, MS4351, College Station, TX 77843-4351. Phone: 979-862-3193;
fax: 979-862-4057.
E-mail address: theresa.morris@tamu.edu (T. Morris).
are the most common major surgery performed in hospitals
across the United States (Podulka, Stranges, & Steiner, 2011).
Despite the increase in cesarean delivery, maternal and fetal
outcomes have not improved (Spong, Berghella, Wenstrom,
Mercer, & Saade, 2012). Cesarean delivery leads to a higher risk
of complications for women and their babies compared with
vaginal birth. Complications to the baby include accidental sur-
gical injury, respiratory problems, and prematurity (this occurs
especially with scheduled cesareans, since gestational age, or
estimated due date, is not always accurate; Dessole et al., 2004;
Gerten, Coonrod, Bay, & Chambliss, 2005; March of Dimes, 2008).
Complications to women include infection, hemorrhage, blood

1049-3867/$ - see front matter 2016 Jacobs Institute of Womens Health. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.whi.2016.02.005

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
330 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335

clots, blood loss, surgical injury, adverse reactions to anesthesia,
and increased risk of placental complications in subsequent
pregnancies (Deneux-Tharaux, Carmona, Bouvier-Colle, & Breart,
2006; Goer, Romano, & Sakala, 2012; Villar et al., 2007). Cesarean
delivery may also hinder breastfeeding success (Zanardo et al.,
2010).
A current maternal health initiative emphasizes reducing
cesarean deliveries among women who are nulliparous (have not
previously given birth), term (
37 weeks gestation), with a
singleton (one) fetus, in a vertex (head down) presentation
(Spong et al., 2012), referred to as NTSV cesarean sections.
Reducing primary (or rst) cesarean sections has the potential to
signicantly lower the overall cesarean delivery rate since they
comprise half of all cesarean deliveries. Further, The Joint Com-
mission has identied the NTSV cesarean section rate as an
important indicator of quality of medical care.1 Since 2014, The
Joint Commission has required hospitals with more than 1,100
annual births to report their NTSV cesarean birth rate, and, since
January 2016, has required hospitals with more than 300 annual
births to report this rate. Further, a major reason for the public
health focus on NTSV cesarean sections is their impact on future
births: nearly all women who have given birth by cesarean sec-
tion will have a repeat cesarean in subsequent pregnancies,
owing to the limited availability of vaginal birth after cesarean in
U.S. hospitals. Prior cesarean section is the single largest
contributor to the increase in the U.S. cesarean rate (Barber et al.,
2011).
Our contribution to this topic is a case study of one hospitals
experience with NTSV cesarean deliveries just before The Joint
Commission required hospital reporting. We conducted a retro-
spective chart review at a tertiary care hospital in an urban city in
New England. Our research focus is on the indication for the
cesarean delivery. Because physician discretion as well as other
factors, including maternal and fetal health status, are involved
in decisions to perform a cesarean, we were interested in
whether race and insurance status affect the probability of
particular indications for cesarean delivery. Biases may seep into
clinician decisions (Barber et al., 2011). Some NTSV cesarean
sections may be performed with little medical justication, and
research has shown an increased risk for African American
women (Caughey, Cahill, Guise, Rouse, & American College of
Obstetricians and Gynecologists, 2014; Getahun, 2009). If
womens race or insurance status inuences indication for ce-
sarean delivery, this information may be used to guide quality
improvement (QI) efforts and health care provider education.
the associated patient record numbers to request womens
medical records, which included electronic records as well as
scanned copies of handwritten records and notes. Although it
would be interesting to examine factors that affected whether
NTSV women had cesarean sections or vaginal births, we do not
have data on NTSV women who had vaginal births, because we
did not have the time or resources to collect data on all NTSV
deliveries.
This hospital had 1,839 deliveries and 1,874 babies born from
June 1, 2013, through November 30, 2013. Of these deliveries,
1,193 (64.9%) were vaginal and 646 (35.1%) were cesarean (313 or
49% repeat cesarean sections and 333 or 51% primary cesarean
sections; Figure 1). We identied 139 patients who had NTSV
cesarean sections or approximately 42% of the primary cesarean
sections.
We collected data from the medical records on the indication
for the cesarean and on patients race and health insurance sta-
tus. Health insurance status is the most accessible and reliable
indication of socioeconomic status in the patient medical record.
The outcome is measured as one of four indications for cesarean
delivery. We categorized three indications as dis-
cretionarydarrest in labor, nonreassuring fetal heart rate, and
cephalopelvic disproportion (CPD)dbecause of the variability
among clinicians in determining whether a cesarean section is
required for these indications and because the increase in pri-
mary cesarean deliveries has been attributed to these indications
in previous research (Barber et al., 2011; Getahun et al., 2009).
The fourth indication relates to a medical reason for a cesarean
section. We categorized this indication as more objective than
the other three indications because, although also subject to the
inherent uncertainties of clinical diagnoses, medical indications
have not been shown to affect the increase in the cesarean sec-
tion rate in institutions over time (Barber et al., 2011).
The discretionary aspect of diagnosing arrest in labor is
related to temporal factors. The American College of

Material and Methods

We conducted a retrospective chart review of NTSV cesarean

deliveries performed at a tertiary care hospital in an urban New
England city between June 1, 2013, and November 30, 2013. The
rst three authors were responsible for data collection and
received institutional review board approval from the hospital
and Trinity College, the authors institution at the time of data
collection. The hospital does not have an entirely electronic
system of medical records, necessitating a multistep data
collection process. We identied women who met the NTSV
criteria by reviewing the birth log (paper record). We then used

1
Although some researchers argue that the NTSV cesarean section rate may
be considered a quality indicator for obstetric care, not all agree with this desig-
nation (Gibson & Bailit, 2015; Main et al., 2006; Snowden, Cheng, Kontgis, &
Caughey, 2012).
Figure 1. Modes of delivery (June 2013November 2013). NTSV, nulliparous (rst
birth), term (
37 weeks gestation), singleton (one baby), vertex (head down
presentation).

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335
Obstetricians and Gynecologists provides guidelines (revised in
2014) for how long women should be allowed to be in certain
stages of labor, but every labor is different and clinician re-
sponses may also differ to the same labor scenario (American
College of Obstetricians and Gynecologists et al., 2014). The
diagnosis of arrest in labor may be owing to a clinicians impa-
tience with a long labor. Thus, time and physician availability
may be deciding factors when a low-risk patient, with a long,
possibly stalled labor, will undergo a cesarean delivery.
Nonreassuring fetal heart rate is also considered a discre-
tionary indication in our model. Most women in labor have the
fetal heartbeat continuously monitored via an external electronic
device. Although the fetal heart rate often decelerates during a
contraction, decelerations can be a cause for concern among
clinicians, who may then recommend an immediate cesarean
section. Fetal status, as measured by electronic fetal monitoring,
is inherently difcult to interpret, and thus clinician discretion
plays a large part in determining when a cesarean delivery is
indicated. The National Institute of Child Health and Human
Development developed a widely accepted categorization of
fetal status from continuous electronic fetal monitoring: cate-
gory I (normal), category II (intermediate), and category III
(abnormal; Macones, Hankins, Spong, Hauth, and Moore, 2008).
Although this seems intuitively cleardcategory I babies are ne;
category III babies are in troubledin practice, most babies fall
into the category II designation at some time during labor
(Pettker & Lockwood, 2008) rate. In addition, because fetal
monitoring has a false-positive rate of 99.8%, it is inherently
challenging to interpret category II tracings (Grimes & Peipert,
2010).
The nal discretionary reason for NTSV cesarean birth is CPD,
where the baby is believed to be too large to t through the
mothers pelvis. This indication is typically invoked during the
second stage of labor, or when a patient who is pushing is
eventually told that the baby is too big and will not t through
the birth canal. However, fetal weight cannot be reliably deter-
mined until the baby is born.
The fourth indication for cesarean birth is medical and in-
cludes what may be considered obstetric or medical indications.
This category includes hypertensive disorders of pregnancy,
chorioamnionitis, gestational diabetes, and other maternal or
fetal conditions that most medical professionals would deem
appropriate reasons for which to perform a cesarean delivery.
We consider this indication objective because there is minimal
variation in the responses (i.e., performance of cesarean section)
across health care providers and facilities (Barber et al., 2011;
Getahun et al., 2009).
We also collected data on three additional variables: use of
Pitocin, weekend delivery, and induction. Pitocin, a drug
administered intravenously to stimulate uterine contractions, is
used to both induce and augment labor. We coded whether or
not women were given Pitocin during their labors. We coded
whether the birth occurred on the weekend or not. Induction is
coded as whether or not the womans labor was induced.2
As indicated, this sample consists of 139 women. Five of the
women had data missing on one or more of the variables, which
2
We had planned to use shift change as a control variable. However, using a
liberal 1-hour period around shift change, we found that few (only 4%) of NTSV
cesarean births were performed during a shift change. Thus, we excluded this
variable from the analysis. We also did not include obesity as a variable. Obesity
did not vary signicantly by womens race or insurance status. Further, because
only 8% of the women were obese, the test of obesity would not be meaningful.
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
331
dropped the sample to 134. Further, we excluded Asian women
from the sample when analyzing race because there were only
three Asian women in the sample. Thus, after excluding the ve
cases with missing data and the three cases of Asian women, we
were left with 131 women in the sample for the analysis of race.
When we analyzed insurance status, we had a sample of 134
because we included the Asian women in that analysis.
Results
Sample Characteristics
Looking at the sample of 134 women, arrest in labor was the
most frequent indication for cesarean delivery (45%) in our
sample (Table 1). The next most frequent indication was non-
reassuring fetal heart rate (28%). The least frequent indications
were medical (13%) and CPD (13%). In terms of the racial distri-
bution of women who had NTSV cesarean deliveries, most were
White (57%), followed by Hispanic (22%), Black (19%), and Asian
(2%) women. Most women (77%) had private health insurance.
The average age was 28.7 years (range, 1643). More than one-
half of women were induced (59%), had Pitocin (61%), and gave
birth on a weekday (70%).
Multivariate Analysis
We used a multinomial logistic model to compute the mar-
ginal effect of each causal variable on the predicted probability of
cesarean indication, controlling for all other causal variables in
the model.3 Long and Freese (2014, p. 415) advocate examining
the marginal effect of causal variables on the predicted proba-
bility of outcomes as a quick and valuable way to examine the
effects of the causal variables on the dependent variable. Such an
interpretation allows one to look at the marginal effect of each
causal variable on the predicted probability of each outcome, in
this case cesarean indication.
We conducted multivariate analysis separately for the causal
variables race and insurance status because race seems to be
capturing an SES difference. For example, 92% of Whites had
private insurance compared with 76% of Blacks and 37% of
Hispanics.
We conducted the multivariate analysis rst for the effect of
race on cesarean indication. In this analysis, the predicted
probability that Black women had a cesarean for CPD was
signicantly lower than the predicted probability that a White
woman had a cesarean for the same indication (0.082; see
Table 2). Hispanic women also had a lower predicted probability
(0.137) of having a cesarean indication of CPD than did White
women. Thus, race was observed to have an effect on the pre-
dicted probability of having a cesarean section for CPD.
When we turn our attention to the other causal variables in
this analysis, we see that weekday and Pitocin had effects on the
predicted probability of indication for cesarean, but Induction
did not. Women who had Pitocin had a higher predicted prob-
ability of having a cesarean for arrest in labor (0.195) and a lower
predicted probability of having a cesarean for CPD (0.071) or for
a medical indication (0.126). This is an important nding,
because Pitocin has not been directly linked to the likelihood of
3
We only display results from the model examining marginal change on pre-
dicted probability of cesarean section indication. This model is based on the
multinomial logistic results. Multinomial logistic results are available from the
authors on request.
332 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335

Table 1 Table 2
Sample Characteristics (n 134) Marginal Effect of Race and Control Variables on Predicted Probability of NTSV
Cesarean Indication (n 131) y
Percent Mean Range
Arrest Nonreassuring Fetal Cephalopelvic Medical
Race
Heart Rate Disproportion
White 56.7
Black 18.7 Pitocin 0.195* 0.002 0.071* 0.126**
Hispanic 22.4 Weekday 0.025 0.032 0.076* 0.068
Asian 2.2 Induced 0.065 0.094 0.001 0.158
Health insurance status Black 0.017 0.045 0.082* 0.055
Private 76.9 Hispanic 0.004 0.123 0.137** 0.018
Medicaid or none 23.1
Abbreviation: NTSV, nulliparous (rst birth), term (
37 weeks gestation),
Age 28.7 1643
singleton (one baby), vertex (head down presentation).
Interventions *
p  .05; **p  .01.
Induced labor 59.0 y
Coefcients displayed show the effect of each causal variable on the pre-
Had Pitocin 61.9
dicted probability of cesarean indication, holding all other causal variables at
Weekend birth 30.6
their means.
Cesarean indication
Arrest in labor 44.8
Nonreassuring fetal heart rate 28.4
Cephalopelvic disproportion 13.4 indication (Table 3).5 We found that the predicted probability of a
Medical 13.4 woman having a cesarean for a nonreassuring fetal heart rate
was signicantly lower for women with private health insurance
than for women without private health insurance (0.154). This
cesarean delivery (Bugg, Siddiqui, & Thornton, 2013). Our nd- might be owing to physicians perception that poor women are
ings show that it is important to distinguish indication for ce- more likely to sue them for medical malpractice (McClellan et al.,
sarean when examining the effect of Pitocin, because Pitocin may 2012). Although this belief is not supported by empirical data, it
have a contradictory effect depending on the indication. The is a widespread belief among physicians (McClellan et al., 2012).
nonnding of Pitocins effect on cesarean section in prior litera- Women with private health insurance also had a lower predicted
ture may be owing to the fact that cesarean sections for varying probability of having a cesarean for a medical indication than did
indications are aggregated, potentially nulling Pitocins effect.4 women without private health insurance (0.088). These nd-
Comparing the absolute value of Pitocins effect on the pre- ings contribute to our understanding of the literature that sug-
dicted probabilities, one can see that the effect of Pitocin is more gests women without private health insurance are more likely to
than twice as strong on the predicted probability for arrest in have cesarean deliveries than women with private health in-
labor and medical indications as it is on the predicted probability surance (Aron, Gordon, DiGiuseppe, Harper, & Rosenthal, 2000;
for CPD. Women who gave birth during the week were also less Haas, Udvarhelyi, & Epstein, 1993; Stafford, 1990) by high-
likely to have a cesarean for CPD (0.076), with a similar lighting the reasons that cesarean deliveries are performed.
magnitude as Pitocins effect on the predicted probability of a These ndings also support the role played by the use of
cesarean for CPD. Pitocin on cesarean deliveries for discretionary indications.
We next display gures of the predicted probability of the Similar to the ndings from the rst multivariate model, Pitocin
different cesarean indications for which the marginal change of increased the predicted probability of a woman having a cesar-
the causal variable on the cesarean indication is statistically ean for arrest in labor (0.186), but decreased the predicted
signicant. These predicted probabilities are based on the earlier probability of a woman having a cesarean for CPD (0.077).
multinomial logistic analysis. We display these gures to further Further, the predicted probability of having a cesarean for a
aid in understanding the impact of the causal variables on the medical indication also decreased with use of Pitocin (0.122).
likelihood of cesarean indication. Figure 2 shows how Pitocin We see, similar to the last model, that the effect of Pitocin was
affects the predicted probability of cesarean delivery for arrest in greatest on arrest in labor. In terms of weekday versus weekend,
labor (holding all other causal variables at their means). Figure 3 we found that women who gave birth on a weekday had a lower
shows the effect of race on the predicted probability of cesarean predicted probability than that of women who gave birth on the
delivery for CPD (holding all other causal variables at their weekend to have a cesarean for CPD (0.082), a nding consis-
means). We do not show the predicted probability charts for day tent with the last analysis. This may indicate that clinicians are
of the week or Pitocins effect on CPD because the predicted more patient with a long second stage of labor on weekdays.
probabilities are too low to make the charts meaningful. We next display gures of the predicted probability of the
Next, we performed a multivariate analysis examining the different cesarean indications for which the marginal change of
effect of insurance status on cesarean indication by using a
multinomial logistic model to compute the marginal effect of
each causal variable on the predicted probability of cesarean

4
Cesarean indication should be used in future research that examines the ef-
fect of Pitocin on mode of delivery. However, it is possible that the effect we nd
of Pitocin on arrest in labor cesarean indication may be owing to a correlation
between Pitocin administration and cesarean for arrest in labor in the setting
of long labors. Our data do not include hours of labor to examine this
association.
5
As before, the multinomial logistic results are not shown but are available Figure 2. Predicted probability of arrest as NTSV C-section indication by Pitocin
upon request. This table shows the marginal change in predicted probability use. NTSV, nulliparous (rst birth), term (
37 weeks gestation), singleton (one
of each cesarean indication and is based on the multinomial logistic analysis. baby), vertex (head down presentation).

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335
Figure 3. Predicted probability of cephalopelvic disproportion (CPD) as NTSV
C-section indication by race. NTSV, nulliparous (rst birth), term (
37 weeks
gestation), singleton (one baby), vertex (head down presentation).
the causal variable on the cesarean indication is statistically
signicant. These predicted probabilities are based on the earlier
multinomial logistic analysis. Figure 4 shows how Pitocin affects
the predicted probability of Arrest and CPD cesarean indications
(holding all other causal variables at their means). Figure 5 shows
the effect of day of the week on the predicted probability of CPD
cesarean indication (holding all other causal variables at their
means). Finally, Figure 6 shows the effect of insurance status on
the predicted probability of nonreassuring fetal heart rate ce-
sarean indication (holding all other causal variables at their
means).
Discussion
Recent efforts to introduce QI strategies to obstetric issues,
particularly overuse of non-medically indicated procedures,
include a national campaign to decrease early elective deliveries
(inductions and cesarean deliveries among women <39
completed weeks gestation; Oshiro et al., 2009). There have also
been systemic efforts to address labor management through QI
strategies of feedback and audit as well as wider culture change
(e.g., obtaining second opinions and changing culture) to reduce
cesarean delivery rates (Chaillet et al., 2006; Chaillet et al., 2007;
Chaillet et al., 2015).
We know from several studies of organizational decision
making that these QI programs are congruent with how orga-
nizations establish protocols that inuence or direct decision
making by employees to further organizational goals (March &
Olsen, 1976). For example, Robin Leidners study of fast food
workers and door-to-door insurance salespeople found that
restaurants and insurance companies structure what might
otherwise be employee decisions, by giving employees scripts,
making it easier for employees to deal with customers and, thus,
Table 3
Marginal Effect of Insurance Status and Control Variables on Predicted Probability
of NTSV Cesarean Indication (n 134)y
Arrest Nonreassuring Cephalopelvic Medical
Fetal Heart Disproportion
Rate
Pitocin 0.186* 0.013 0.077** 0.122**
Weekday 0.052 0.046 0.082** 0.088
Induced 0.068 0.103 0.023 0.148
Insurance Status 0.066 0.154** 0.309 0.088**
Abbreviation: NTSV, nulliparous (rst birth), term (
37 weeks gestation),
singleton (one baby), vertex (head down presentation).
*
p  .05; **p  .01.
y
Coefcients displayed show the effect of each causal variable on the pre-
dicted probability of cesarean indication, holding all other causal variables at
their means.
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
333
Figure 4. Predicted probability of arrest and cephalopelvic disproportion (CPD) as
NTSV C-Section indication by Pitocin use. NTSV, nulliparous (rst birth), term (
37
weeks gestation), singleton (one baby), vertex (head down presentation).
facilitate organizational goals (Leidner, 1993). However, research
has also shown that the human factor in organizations can never
be controlled fully (Jaffee, 2001). Humans adapt in various, often
unpredictable, ways to organizational protocols, thus allowing
their own thoughts, interests, and biases to inuence their de-
cisions. For example, research has demonstrated that race affects
how women are treated during labor and birth by maternity
clinicians (Morris & Schulman, 2014).
Our research demonstrates that biases related to patients
race and class might affect NTSV cesarean indication. Our nd-
ings give a nuanced view into how stratication affects birth and
are aligned with previous research that examines how insurance
status and race affect the likelihood of cesarean delivery (Aron
et al., 2000; Braveman, Egerter, Edmonston, & Verdon, 1995;
Getahun et al., 2009; Haas et al., 1993; Stafford, 1990). Depend-
ing on their race and insurance status, women may be more or
less likely to have a cesarean section for a particular indication,
and this is supported by research on primary cesarean sections
(Washington, Caughey, Cheng, & Bryant, 2012).
The research on NTSV cesarean section is relatively new, and
our study is one of the few to examine factors associated with
various indications for cesarean delivery. Edmonds, Yehzekel,
Liao, and Simas (2013) found that Black and Asian women
were more likely to have NTSV cesarean sections than were
White women and that Black women were more likely than
White women to have an NTSV cesarean for fetal distress
(Edmonds et al., 2013). That study focused on a single hospital
over 5 years (20062011). Note the years of that study were well
before the Joint Commissions focus on the NTSV cesarean rate as
a quality indicator and, thus, likely also preceded clinicians
attention to the measure.
We suggest that examining one hospitals NTSV cesarean
indication trend is an important piece of the puzzle in trying to
understand why some women have cesarean deliveries. Case
studies can advance understanding of how a hospitals organi-
zational culture may contribute to overuse of cesarean delivery,
especially among rst-time, low-risk pregnant women. As one
Figure 5. Predicted probability of cephalopelvic disproportion (CPD) as NTSV
C-Section indication by day of week. NTSV, nulliparous (rst birth), term (
37
weeks gestation), singleton (one baby), vertex (head down presentation).
334 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335
Figure 6. Predicted probability of non-reassuring fetal heart rate (NRFHR) as NTSV
C-Section indication by insurance status. NTSV, nulliparous (rst birth), term (
37
weeks gestation), singleton (one baby), vertex (head down presentation).
study found, the fact that cesarean delivery rates and practices
vary widely among states, regions, hospitals, and providers.
demonstrates that hospitals and clinicians can differ in their
responses to the same conditions (Main et al., 2011, p. 9.). To put
this in perspective, there is a 15-fold variation in hospital ce-
sarean rates for low-risk women (Kozhimannil, Law, & Virnig,
2013). Understanding which indications are driving cesarean
deliveries among different types of women is a key contribution
of our case study approach. Having said that, the usefulness of
case studies should not preclude researchers from conducting
more generalizable, multi-hospital studies. Both types of studies
have the ability to advance our understanding of what contrib-
utes to the overuse of NTSV cesarean delivery.
We have several suggestions for future research. First, we
strongly suggest that researchers track outcomes by provider,
because we are almost certain there will be providers who are
more likely to perform NTSV cesarean sections, and, once iden-
tied, QI efforts can focus on these individuals. We tried to collect
this information, but the hospital institutional review board
denied our request based on privacy concerns. Researchers
ability to deal with privacy concerns on this issue will be
important in navigating hospital institutional review board
processes. We also suggest the importance of longitudinal
research, which would allow researchers not only to see changes
over time, but also to evaluate the conditions and practices that
lead to desired changes.
Implications for Practice and/or Policy
We came to this topic through the public health focus on the
need to decrease cesarean deliveries among low-risk women in
their rst pregnancies. Hospitals have different practices and
patterns of cesarean delivery; this retrospective chart review
conducted in one hospital allows us to understand the local
picture and can inform tailored QI strategies. If hospitals can
identify the reasons for NTSV cesareans and engage in QI ini-
tiatives that focus on these indications, they will likely observe
decreases in these cesarean deliveries.
Our ndings can inform QI efforts by identifying likely soci-
odemographic trends among various indications for cesarean
delivery. For change to occur at the unit level, hospitals may
undertake studies such as this to explore trends and identify
areas for improvement. As the Joint Commission continues to
require hospitals to report on perinatal core measures, and other
national initiatives aim to reduce the NTSV cesarean rate, this
issue will become relevant to all birthing facilities and child-
bearing women in the United States.
References
American College of Obstetricians and Gynecologists, Society for Maternal-Fetal
Medicine, Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
prevention of the primary cesarean delivery. American Journal of Obstetrics
and Gynecology, 210(3), 179193.
Aron, D. C., Gordon, H. S., DiGiuseppe, D. L., Harper, D. L., & Rosenthal, G. E.
(2000). Variations in risk-adjusted cesarean delivery rates according to race
and health insurance. Medical Care, 38(1), 3544.
Barber, E. L., Lundsberg, L. S., Belanger, K., Pettker, C. M., Funai, E. F., & Illuzzi, J. L.
(2011). Indications contributing to the increasing cesarean delivery rate.
Obstetrics and Gynecology, 118(1), 2938.
Braveman, P., Egerter, S., Edmonston, F., & Verdon, M. (1995). Racial/ethnic dif-
ferences in the likelihood of cesarean delivery, California. American Journal of
Public Health, 85(5), 625630.
Bugg, G. J., Siddiqui, F., & Thornton, J. G. (2013). Oxytocin versus no treatment or
delayed treatment for slow progress in the rst stage of spontaneous labour.
Cochrane Database of Systematic Reviews(6), CD007123.
Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. C., & American College of
Obstetricians and Gynecologists (2014). Safe prevention of the primary ce-
sarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179
193.
Chaillet, N., Dube, E., Dugas, M., Francoeur, D., Dube, J., Gagnon, S., . Dumont, A.
(2007). Identifying barriers and facilitators towards implementing guide-
lines to reduce caesarean section rates in Quebec. Bulletin of the World Health
Organization, 85(10), 791797.
Chaillet, N., Dube, E., Dugas, M., Audibert, F., Tourigny, C., Fraser, W. D., &
Dumont, A. (2006). Evidence-based strategies for implementing guidelines
in obstetrics: a systematic review. Obstetrics and Gynecology, 108(5), 1234
1245.
Chaillet, N., Dumont, A., Abrahamowicz, M., Pasquier, J. C., Audibert, F., &
Monnier, P. (2015). A cluster-randomized trial to reduce cesarean delivery
rates in Quebec. New England Journal of Medicine, 372(18), 17101721.
Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M. H., & Breart, G. (2006).
Postpartum maternal mortality and cesarean delivery. Obstetrics and Gyne-
cology, 108(3 Pt 1), 541548.
Dessole, S., Cosmi, E., Balata, A., Uras, L., Caserta, D., Capobianco, G., &
Ambrosini, G. (2004). Accidental fetal lacerations during cesarean delivery:
Experience in an Italian level III university hospital. American Journal of
Obstetrics and Gynecology, 191(5), 16731677.
Edmonds, J. K., Yehzekel, R., Liao, X., & Simas, T. A. M. (2013). Racial and ethnic
differences in primary, unscheduled cesarean deliveries among low-risk
primiparous woman at an academic medical center: A retrospective
cohort study. BMC Pregnancy & Childbirth, 13, 168.
Gerten, K. A., Coonrod, D. V., Bay, R. C., & Chambliss, L. R. (2005). Cesarean de-
livery and respiratory distress syndrome: Does labor make a difference?
American Journal of Obstetrics and Gynecology, 193(3 Pt 2), 10611064.
Getahun, D., Strickland, D., Lawrence, J. M., Fassett, M. J., Koebnick, C., &
Jacobsen, S. J. (2009). Racial and ethnic disparities in the trends in primary
cesarean delivery based on indications. American Journal of Obstetrics and
Gynecology, 201(4), 422.e421422.e427.
Gibson, K., & Bailit, J. L. (2015). Cesarean delivery as a marker for obstetric
quality. Clinical Obstetrics and Gynecology, 58, 211216.
Goer, H., Romano, A., & Sakala, C. (2012). In. Vaginal or cesarean birth: What is at
stake for women and babies. New York: Childbirth Connections.
Grimes, D. A., & Peipert, J. F. (2010). Electronic fetal monitoring as a public health
screening program: The arithmetic of failure. Obstetrics and Gynecology,
116(6), 13971400.
Haas, J. S., Udvarhelyi, S., & Epstein, A. M. (1993). The effect of health coverage for
uninsured pregnant women on maternal health and the use of cesarean
section. JAMA, 270(1), 6164.
Hamilton, B. E., Martin, J. A., Osterman, M. J. K., Curtin, S. C., & Mathews, T. J.
(2015). Births: Final data for 2014. National Vital Statistics Report, 64(12),
163.
Jaffee, D. (2001). Organization theory: Tension and change. Boston: McGraw-Hill.
Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary
tenfold among US hospitals; Reducing variation may address quality and
cost issues. Health Affairs (Millwood), 32(3), 527535.
Leidner, R. (1993). Fast food, fast talk: Service work and the routinization of
everyday life. Berkeley: University of California Press.
Long, J. S., & Freese, J. (2014). Regression models for categorical dependent variables
using Stata. College Station, TX: StataCorp LP.
Macones, G. A., Hankins, G. D., Spong, C. Y., Hauth, J., & Moore, T. (2008). The
2008 National Institute of Child Health and Human Development Workshop
on Electronic Fetal Monitoring: Update on denitions, interpretation, and
research guidelines. 3rd ed. Obstetrics & Gynecology, 112(3), 661666.
Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., .
Sterling, J. (2006). Is there a useful cesarean birth measure? Assessment of
the nulliparous term singleton vertex cesarean birth rate as a tool for ob-
stetric quality improvement. American Journal of Obstetrics and Gynecology,
194(6), 16441651, discussion 1651-1642.
Main, E. K., Morton, C. H., Hopkins, D., Giuliani, G., Melsop, K., & Gould, J. B.
(2011). Cesarean deliveries, outcomes, and opportunities: Towards a public
agenda for maternity care safety and quality. Palo Alto, CA: California Maternal
Quality Care Collaborative. Available: www.cmqcc.org. Accessed February
18, 2016.
 T. Morris et al. / Women's Health Issues 26-3 (2016) 329335
March, J. G., & Olsen, J. P. (1976). Ambiguity and choice in organizations. Bergen:
Universitetsforlaget.
March of Dimes. (2008). News: C-Sections a critical factor in preterm birth in-
crease. Faireld, CT: Author.
McClellan, F. M., White, A. A., III, Jimenez, R. L., & Fahmy, S. (2012). Do poor people sue
doctors more frequently? Confronting unconscious bias and the role of cultural
competency. Clinical Orthopaedics and Related Research, 470, 13931397.
Morris, T., & Schulman, M. (2014). Race inequality in epidural use and regional
anesthesia failure in labor and birth: An examination of womens experi-
ence. Sexual and Reproductive Healthcare, 5(4), 188194.
Oshiro, B. T., Henry, E., Wilson, J., Branch, D. W., Varner, M. W., & Women, &
Newborn Clinical Integration, P (2009). Decreasing elective deliveries before
39 weeks of gestation in an integrated health care system. Obstetrics and
Gynecology, 113(4), 804811.
Pettker, C. M., & Lockwood, C. J. (2008). New standards for FHR assessment:
Something old and something new. Contemporary OB/GYN, 53(2), 1012.
Podulka, J., Stranges, E., & Steiner, C. (2011). Hospitalizations Related to Childbirth,
2008 HCUP Statistical Brief #10. Rockville, MD: Agency for Healthcare
Research and Quality.
Snowden, J. M., Cheng, Y. W., Kontgis, C. P., & Caughey, A. B. (2012). The
association between hospital obstetric volume and perinatal outcomes in
California. American Journal of Obstetrics and Gynecology, 207(6), 478.e471
478.e477.
Spong, C. Y., Berghella, V., Wenstrom, K. D., Mercer, B. M., & Saade, G. R. (2012).
Preventing the rst cesarean delivery: Summary of a Joint Eunice Kennedy
Shriver National Institute of Child Health and Human Development, Society
for Maternal-Fetal Medicine, and American College of Obstetricians and
Gynecologists Workshop. Obstetrics and Gynecology, 120(5), 11811193.
Stafford, R. S. (1990). Cesarean section use and source of payment: An analysis of
California hospital discharge abstracts. American Journal of Public Health,
80(3), 313315.
Villar, J., Carroli, G., Zavaleta, N., Donner, A., Wojdyla, D., Faundes, A., . Perinatal
Health Research, G (2007). Maternal and neonatal individual risks and
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
335
benets associated with caesarean delivery: Multicentre prospective study.
BMJ, 335(7628), 1025.
Washington, S., Caughey, A. B., Cheng, Y. W., & Bryant, A. S. (2012). Racial and
ethnic differences in indication for primary cesarean delivery at term:
Experience at one U.S. Institution. Birth, 39(2), 128134.
Zanardo, V., Svegliado, G., Cavallin, F., Giustardi, A., Cosmi, E., Litta, P., &
Trevisanuto, D. (2010). Elective cesarean delivery: Does it have a negative
effect on breastfeeding? Birth, 37(4), 275279.
Author Descriptions
Theresa Morris, PhD, is Associate Professor of Sociology at Texas A&M University.
Her research applies political-economic and organizational theories to reproduc-
tion. Her book Cut It Out: The C-Section Epidemic in America explores the Caesarean
section rate from this perspective.
Olivia Meredith, BA, holds a degree in Sociology from Trinity College in Hartford,
Connecticut. She is currently Staff for Special Projects in the Student Outreach and
Support Department at MIT.
Mia Schulman, BA, holds a degree in Sociology from Trinity College. She is a Pro-
gram Associate at the Tiger Foundation in New York City and volunteers with
Choices in Childbirth, a nonprot that educates and advocates for more options in
childbirth.
Christine H. Morton, PhD, is research sociologist at California Maternal Quality Care
Collaborative at Stanford University, where she works on projects related to
maternal mortality and morbidity as well as cesarean birth reduction quality
improvement.