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This report presents recent findings for 2013 on four maternal morbidities associated with labor and delivery-maternal transfusion, ruptured uterus, unplanned hysterectomy, and intensive care unit (ICU) admission-that are collected on birth certificates for a 41-state and District of Columbia reporting area, which represents 90% of all births in the United States., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Background: The cesarean rate has served an integral role in the monitoring of obstetrical care, and in 2002, the national rate reached 26.1%, the highest ever reported., Objective: We sought to describe the effect of clinical complications on hospital cesarean rates., Research Design: This was a population-based cohort study., Subjects: All laboring women without a previous cesarean who delivered in California in 1995 as reported through public-use hospital discharge data were included., Measures: Women with and without maternal, fetal, or placental complications were compared with respect to cesarean use. Using recursive partitioning algorithms, women with complications were stratified into clinically homogeneous categories, which were analyzed separately with respect to cesarean use., Results: The 443,532 women delivered at 288 hospitals and included 116,170 women (26.2%) in the complicated group (cesarean rate 22.6%); and 327,362 women (73.8%) in the uncomplicated group (cesarean rate 6.7%). At the hospital level, the cesarean rates among the complicated and uncomplicated patients respectively were: median 23.5% (range, 2.2-9.9%); and median 6.5% (range, 1.8-18.2%). Recursive partitioning algorithms suggested 16 distinct clinical categories, with cesarean rates varying from 8.9% for women with asthma to 84.5% for women with an unengaged fetal head., Conclusions: Cesarean rates varied widely across complication types, and complication-specific rates varied widely among hospitals. Although the presence of pregnancy complications upon hospital admission comprised the strongest factor affecting first-time cesarean use among laboring women, the importance and interdependence of these clinical conditions has yet to be incorporated into commonly used models for cesarean rate comparisons.

Objective: To develop a methodology to identify indications and normative rates for elective primary cesarean delivery using administrative data., Data Sources/study Setting: All delivery discharges in 1995, as reported to the California Office of Statewide Health Planning and Development (secondary data)., Study Design: Retrospective population based study., Data Collection/extraction: Data were entered into a recursive partitioning algorithm to develop a hierarchy of conditions by which patients with multiple conditions could be sorted with respect to the binary outcome of labor or elective primary cesarean without labor. This hierarchy was examined for its clinical consistency, validated on a second sample, and compared with results obtained from logistic regression., Principal Findings: Four percent (19,664) of delivery discharges in 1995 underwent elective primary cesarean. Twelve clinical conditions contributed to the hierarchy, and accounted for 92.9 percent of all women experiencing elective primary cesarean delivery. The remaining 7.1 percent of the elective primary cesarean cases were classified as "unspecified.", Conclusions: A standardized methodology (utilizing recursive partitioning algorithms) for assigning indications for elective primary cesarean is presented. This methodology relies on administrative data, classifies women with complex comorbidity patterns into clinically relevant subpopulations, and can be used to establish normative rates for benchmarking specific indications for cesarean delivery.