Examining How Factors Associated with Patients, Physicians, Hospitals, and Surrounding Communities Affect Primary and Repeat Cesarean Delivery Through a Social-Ecological Lensedit
Childbirth is one of the most common reasons for hospitalization in the U.S., and Cesarean delivery (i.e., surgical childbirth) is costlier and has a higher likelihood of birth-related complications, maternal rehospitalization, and postpartum medical care utilization than vaginal delivery. The rate of Cesarean delivery in the United States (U.S.) has increased in recent years by over 60%, from 20.7% of all births in 1996 to 32.9% of all births in 2011. As Although this increasing trend of Cesarean delivery incidence has also been seen in other countries, the rate of Cesarean delivery has been rising more steadily within the U.S. than nearly anywhere else. While Cesarean delivery has been established as the safer delivery option for women with certain high-risk pregnancy complications that could put mother and/or baby in danger during vaginal delivery, the increasing rate of Cesarean delivery in the U.S. has not been accompanied with a concomitant decrease in maternal and neonatal morbidity and mortality. Therefore, it has been suggested that at least some Cesarean deliveries performed may be clinically unnecessary, and may put pregnant women at an avoidable higher risk of adverse health outcomes. Numerous factors across multiple levels of organization have been linked to influencing the likelihood of a pregnant woman receiving a Cesarean delivery. Firstly, a robust body of evidence has linked numerous clinical facets of pregnancy, either related to maternal health specifically (e.g., gestational diabetes) or fetal health presentations (e.g., fetal malpresentation), to increased Cesarean delivery likelihood. Additionally, certain sociodemographic characteristics, such as being of older age or being of black/African-American race, have been linked to a higher risk of having a Cesarean delivery. Numerous factors beyond the pregnant woman herself, however, have also been linked to the likelihood of a Cesarean delivery occurring, through a social-ecological framework. Practice-related (e.g., clinical experience, medical school location) and sociodemographic characteristics (e.g., age, gender) of the physician presiding over the birth have been shown to affect Cesarean delivery occurrence. Furthermore, aspects of the hospital where the birth occurs related to maternity health-related practices (e.g., vaginal birth after Cesarean occurrence) and ownership/affiliation (e.g., teaching status, private ownership) have been associated with influencing Cesarean delivery likelihood in numerous studies. Lastly, while there is a dearth of information as to how the health of communities where pregnant women live specifically affect Cesarean delivery likelihood, the sociodemographic profile of communities have been linked to other adverse pregnancy outcomes (e.g., preterm birth, low birthweight). As such, this dissertation research examined: 1) the role of sociodemographic and maternal health-related characteristics of communities related to overall and maternal health characterize in influencing Cesarean delivery incidence across ZIP codes in New York State (NYS); 2) how characteristics associated with pregnant women, physicians, hospitals and patient residential communities affect primary Cesarean delivery risk in pregnant women in NYS; and, 3) how the factors aforementioned in step 2 above affect repeat Cesarean delivery risk in pregnant women in NYS.