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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Cedars Sinai Medical Center and the George Burns Research Institute, and the University of California, Los Angeles School of Medicine, Los Angeles, California.
Address reprint requests to: Kimberly D. Gregory, MD, MPH, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Suite 160 West, Los Angeles, CA 90048, E-mail: gregory{at}cshs.org
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Abstract |
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Methods: In a retrospective study using administrative discharge data from Los Angeles County, California, we calculated the vaginal breech delivery rates of singleton breech deliveries during calendar years 1988 and 1991.
Results: Ten thousand four hundred breech deliveries were identified, 8988 (86.4%) term and 1412 (13.6%) preterm. Twelve percent (1252 of 10,400) were vaginal deliveries (10.1% term and 24.5% preterm). Term vaginal breech deliveries varied by hospital type and were more frequent in public hospitals (28.4%, 95% confidence interval [CI] 26.1%, 30.7%) and less frequent in private nonteaching hospitals (5.4%, 95% CI 4.8%, 5.9%). Term vaginal deliveries were 2.4 to 11.3 times more likely among black women and 1.3 to 6.3 times more likely for Hispanic women across all hospital types, compared with white women in private nonteaching hospitals. There was no difference in the proportion of preterm vaginal breech deliveries by hospital type (mean 24.5%). However, with the exception of public hospitals, the proportion of vaginal breech deliveries for both term and preterm deliveries varied significantly by ethnicity.
Conclusion: The use of vaginal breech delivery varied by hospital type and patient ethnicity. Within private teaching and nonteaching hospitals, vaginal breech delivery was more likely for black women than for women of other ethnic groups. Further study is needed to understand the hospital policies or organizational factors, as well as the patient-related sociocultural and clinical factors, that contribute to those differences.
There has been considerable publicity with respect to recommendations to lower the national cesarean rate from current rates of over 20%1 to the Healthy People 2000 goal of 15%.2,3 Researchers and health policy analysts have suggested many strategies to achieve that goal, including more aggressive labor management for dystocia,3 increased use of vaginal birth after cesarean (VBAC),3,4 more objective criteria for diagnosing non-reassuring fetal status,3 and decreasing the number of cesareans for breech presentation by increasing either the use of external cephalic version3,5,6 or the number of vaginal breech deliveries.3,7,8 Although only 3% of all singleton births involve infants with breech presentation, 13% of all cesareans are performed for this indication.1 Nationwide, 86% of infants with breech presentation were delivered by cesarean,9 despite evidence that vaginal breech delivery can be a reasonable alternative.7,8
Widespread resistance to vaginal breech delivery is associated with several factors. The relative safety of vaginal breech delivery remains controversial.9–14 Hospital characteristics can influence preferred delivery route via several mechanisms.15 For example, hospital staffing structure and malpractice coverage can affect the degree to which individual physicians counsel patients and accept the liability risks of vaginal breech delivery. Likewise, teaching obligations of academic institutions might result in formal policies that promote or encourage vaginal breech birth. One overlooked consideration might be the patient case mix of the hospital. Recognizing the ongoing national imperative to address racial and ethnic disparities in access to health care services and health outcomes, we suggest that research is needed in women’s health in order to identify clinical conditions and procedures where variation by race or ethnicity occurs. Socioeconomic status, ethnicity, and clinical conditions might affect how patients are counseled or perceive risks of vaginal breech birth.16–18 Because the health care industry rapidly is embracing health care profiling, benchmarking, and the use of report cards to compare clinical outcomes, an understanding of the relationship between hospital case mix and procedures used as clinical indicators has become important.
The objective of this study was to determine the extent to which vaginal breech delivery varied by hospital type. We hypothesized that private nonteaching hospitals would have the lowest vaginal breech delivery rates compared with other hospital types, and we wanted to determine whether there was variation in vaginal breech delivery by race or ethnicity.
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Materials and Methods |
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After separating term and preterm deliveries, the percentage of patients delivering vaginally in each hospital category was calculated and stratified by ethnicity because of the known differences in ethnic distribution associated with each hospital type and with preterm birth. Confidence intervals (CI) for each of the percentages were calculated, and relative risks (RR) and their 95% CI were determined by the absolute proportions and their standard errors, with white women delivering in a private nonteaching hospital as the referent group. To determine whether any adjustment of these values was needed, a hierarchically correct multivariable logistic regression model that included the variable of interest (hospital type), the potential factors for adjustment (ethnicity, prematurity [yes/no], maternal age [years], and year of delivery [1988 or 1991]) and all potential interactions was constructed to describe the outcome of vaginal delivery (c statistic = 0.74). Logistic regression modeling was performed with PC SAS 6.12 (SAS Institute, Cary, NC). Maternal age, year of delivery, and the interaction terms did not contribute to the stratified analysis. Hence, only the simpler, stratified analysis is presented here. Statistical significance was defined as P < .05.
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Results |
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Distributions of vaginal births by hospital type and ethnicity are given in Tables 1
and 2. With respect to term deliveries, there was wide variation in the percentage of vaginal births across hospital types (Table 1). Private nonteaching hospitals had a lower percentage of vaginal breech deliveries than all other hospitals (5.4%, 95% CI 4.8%, 5.9%), and public hospitals had a higher percentage than all other hospitals (28.4%, 95% CI 26.1%, 30.7%). Using term deliveries of white women in a private nonteaching hospital as the referent group, there were no differences in the RR for term vaginal delivery of white women for any of the other hospital types (HMO, private teaching) except for public hospitals, for which there was a large difference (Table 3). White women who delivered in public hospitals were 7.9 times more likely (95% CI 5.2, 12.0) to have vaginal breech delivery compared with white women who delivered in private nonteaching hospitals. Conversely, there was significant variation in the RR of term vaginal breech delivery for black women across the different hospital types. Black women were 2.4 to 11.3 times more likely to have vaginal breech delivery, depending on the hospital type, compared with the reference group. Term deliveries of Hispanic women in private nonteaching hospitals were similar to those of the reference group, but for all other hospital types, Hispanic women were 2.2 to 6.3 times more likely to have term breech vaginal delivery. Among women delivered in HMOs or public hospitals, there were significant differences in rates of term vaginal breech delivery compared with the referent group. However, there were no differences in the proportion of term vaginal breech deliveries in each ethnic category among women delivered in HMOs or public hospitals (ie, confidence intervals within the hospital stratum overlap).
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), there were no differences in the proportion of vaginal breech deliveries by hospital type. The proportion of vaginal breech deliveries across the four hospital types varied from 21.2% (HMO) to 27.5% (public), and averaged 24.5% (95% CI 22.3%, 26.7%). When stratified by ethnicity, the proportions differed markedly across hospital types. There was no difference in the proportion of vaginal breech deliveries by ethnicity among public hospitals. However, for the other three hospital types, the proportion of vaginal preterm breech deliveries ranged from 15.9% (private nonteaching) to 19.2% (HMO) for white women; 38.9% (HMO) to 50% (private teaching) for black women; and 10.0% (HMO) to 27.4% (private nonteaching) for Hispanic women.
Using term deliveries of white patients in a private nonteaching hospital as the reference group, all preterm deliveries (except in Hispanic HMO patients) were more likely to have been vaginal breech (Table 3). Among preterm deliveries, black women had a higher risk of vaginal breech delivery compared with other ethnic groups within the specific hospital types. For example, the increased RR for vaginal breech delivery varied from a low of 4.3–8.7 for other ethnic groups, 2.3–6.4 for Hispanics, and 7.3–11.6 for blacks.
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Discussion |
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The increased use of vaginal breech delivery among preterm patients (25% compared with 10%) is consistent with other population-based studies9,22–26 but is somewhat surprising in light of ongoing debate about the relative safety of cesarean delivery for this patient population. Factors that might decrease the likelihood of cesarean delivery in the preterm population include advanced labor or periviability based on clinical estimate of gestational age.16 We were not able to assess cervical dilatation on admission or gestational age at delivery from the maternal administrative discharge data. Differences in clinical management concerning viability deserve further exploration in this patient population. Studies found that obstetricians tend to underestimate viability and therefore limit aggressive procedures accordingly.27
Our results indicated that the proportion of breech deliveries that are preterm is approximately the same across hospital types (12–17%) and that each hospital type delivers the same percentage of their preterm breeches vaginally (25%). Despite this apparent uniformity, there is a wide range of vaginal breech deliveries across ethnic groups (9–42%), with black women having higher rates within each hospital type. Although similar overall preterm vaginal breech delivery rates might suggest that factors associated with preterm delivery might be evenly distributed across hospital types, variation by ethnicity suggests that other unmeasured factors or processes also are important. The fact that black women have nearly twice the preterm birth rate compared with other ethnic groups does not explain the differences seen in our stratified analysis. Rayl et al26 in a case-control study of risk factors for breech presentation found that black women were less likely to have breech presentation after controlling for birth weight, gestational age, parity, and maternal age. Previous studies have not found a consistent relationship between cesarean delivery and race or ethnicity. This could result from regional differences or methodologic processes that do not stratify or control for key clinical subsets of conditions, such as prematurity.
Unmeasured factors might affect decisions regarding mode of delivery and manifest through ethnic differences. Intrinsic hospital factors might include how patients are screened or how consent is obtained. Factors extrinsic to the hospital might include the patients clinical presentation, ethnic or cultural differences in patient preferences for vaginal delivery, or differences in how personal or fetal risk is interpreted after receiving informed consent. Our lack of understanding of these differences in delivery choices by hospital characteristics and ethnicity impedes the implementation of Healthy People 2000 recommendations.
Our study has several limitations. Because we relied on secondary administrative data, there is an inherent risk of ascertainment bias and misclassification bias leading to incorrect assignment of cases or delivery method. However, the State of California maintains concurrent quality assurance measures to ensure integrity and validity of their database.28 This study was based solely on maternal discharge data and was not linked to neonatal data. Therefore, we are unable to comment on neonatal outcomes. This limitation is particularly relevant regarding our finding of increased likelihood of vaginal breech delivery in preterm infants. Patient-specific information on gestational age or estimated fetal weight would have been useful.
Although there is widespread academic interest in vaginal breech delivery, we found that it is done in limited clinical settings, which raises important policy questions. First, the acquisition of technical experience in vaginal breech delivery is limited to specific clinical settings. In Los Angeles County, public hospitals train approximately half of graduating obstetricians but provide care for a relatively small group of obstetric patients, approximately 35% of Medicaid patients in Los Angeles County.19 Based on that situation, residents working in other settings are less likely to learn the skills associated with vaginal breech delivery. If our findings are generalizable to other urban areas, a relatively small proportion of physicians with skills in vaginal breech delivery will enter the workforce; therefore, this skill is likely to be lost.29,30 Second, there is conflicting information regarding the short-term and long-term neonatal morbidity associated with vaginal breech delivery. This lack might, in part, be due to failure to control for patient ethnicity, as well as prematurity or gestational age at delivery, and other selection biases such as planned versus unplanned vaginal delivery or analysis by intended mode of delivery. Including these factors should be a prerequisite for future studies in order to make meaningful comparisons, especially when interpreting data related to neurologic development, because some ethnic groups could be at risk for socioeconomic or environmental disadvantages, while being at increased risk for vaginal breech delivery.
Third, the strength of the association between these patient factors (ethnicity, prematurity, and hospital type) and the likelihood of vaginal breech delivery suggests that there are sociocultural factors or clinical and hospital policies regarding patient selection for vaginal breech delivery. Qualitative factors driving health care processes and outcomes should be included in research efforts to understand objectives and values that determine provision of care. This will require interdisciplinary collaboration between clinicians, administrators, and researchers to develop the methodologic tools to guide health care policy.
Lastly, this study did not address whether vaginal breech delivery was underutilized in private hospitals or overutilized in public hospitals. Likewise it did not address whether there are differences in how providers interact, counsel, or treat patients on the basis of the patient’s ethnicity. It does provide a framework for further investigation regarding the organizational milieu that guides clinical practices in different types of hospitals and adds further support to existing literature regarding the importance of tracking health care outcomes for different ethnic groups.17,18
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Footnotes |
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Received April 28, 2000. Received in revised form September 5, 2000. Accepted October 13, 2000.
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References |
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2. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS publication PHS 91-50212. Washington, DC: United States Department of Health and Human Services, Public Health Service, 1991.
3. Cesarean childbirth: Report of a consensus development conference. Bethesda, Maryland: National Institutes of Health, 1981.
4. American College of Obstetricians and Gynecologists. Vaginal delivery after a previous cesarean birth. ACOG committee opinion no. 143. Washington, DC: American College of Obstetricians and Gynecologists, 1995.
5. Gifford DS, Keeler E, Kahn KL. Reduction in cost and cesarean rate by routine use of external cephalic version: A decision analysis. Obstet Gynecol 1985;85:930–6.
6. Zhang J, Bowes WA, Fortney JA. Efficacy of external cephalic version: A review. Obstet Gynecol 1993;82:306–12.
7. Collea JV, Rabin SC, Weghorst GR, Quilligan EJ. The randomized management of term frank breech presentation: A study of 208 cases. Am J Obstet Gynecol 1980;137:235–42.[Medline]
8. Gimovsky ML, Wallace RL, Schifrin BS, Paul RH. Randomized management of the non-frank breech presentation at term. A preliminary report. Am J Obstet Gynecol 1983;146:34–40.[Medline]
9. Lee KS, Khoshnood B, Sriram S, Hsieh HL, Singh J, Mittendorf R. Relationship of cesarean delivery to lower birth weight-specific neonatal mortality in singleton breech infants in the United States. Obstet Gynecol 1998;92:769–74.[Abstract]
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13. Croughan-Minihane MS, Petitti DB, Gordis L, Golditch I. Morbidity among breech infants according to method of delivery. Obstet Gynecol 1990;75:821–5.
14. Grant A, Penn ZJ, Steer PJ. Elective or selective cesarean delivery of the small baby? A systemic review of the controlled trials. Br J Obstet Gynaecol 1996;103:1197–200.[Medline]
15. Stafford RS. Cesarean section use and source of payment: An analysis of California hospital discharge abstracts. Am J Public Health 1990;80:313–5.
16. Anderson G, Strong C. The premature breech: Caesarean section or trial of labour? J Med Ethics 1988;14:18–24.[Abstract]
17. Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988. Am J Public Health 1995;85:352–6.
18. Bronstein JM, Cliver SP, Goldenberg RL. Practice variation in the use of interventions in high-risk obstetrics. Health Serv Res 1998; 32:825–39.[Medline]
19. Gregory KD, Ramicone E, Chan L, Kahn KL. Cesarean deliveries for medicaid patients: A comparison in public and private hospitals in Los Angeles County. Am J Obstet Gynecol 1999;180:1177–84.[Medline]
20. Cibils LA, Karrison T, Brown L. Factors influencing neonatal outcomes in the very-low-birth-weight fetus (<1500 grams) with a breech presentation. Am J Obstet Gynecol 1994;17:35–42.
21. Zlatnik FJ. The Iowa premature breech trial. Am J Perinatol 1993;10:60–3.[Medline]
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23. Kiely JL. Mode of delivery and neonatal death in 17587 infants presenting by the breech. Br J Obstet Gynaecol 1991;98:898–904.[Medline]
24. Bingham P, Lilford RJ. Management of the selected term breech presentation: Assessment of the risks of selected vaginal delivery versus cesarean section for all cases. Obstet Gynecol 1987;69:965–78.[Medline]
25. Duenhoelter JH, Wells CE, Reisch JS, Santos-Ramos R, Jimenez JM. A paired controlled study of vaginal and abdominal delivery of the low birthweight fetus. Obstet Gynecol 1979;54:310–3.
26. Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol 1996;174:28–32.[Medline]
27. Haywood JL, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Comparison of perceived and actual rates of survival and freedom from handicap in premature infants. Am J Obstet Gynecol 1994; 171:432–9.[Medline]
28. Meux EF, Stih A, Zoch A. A report of results from the OSHPD reabstracting project: An evaluation of the reliability of selected patient discharge data (July through December 1988). Sacramento, California: State of California, Patient Discharge Data Section Office of Statewide Health Planning and Development, 1990.
29. Spellacy WN. Point/counterpoint: I. A viable fetus presenting as a breech in labor needs a cesarean delivery. Obstet Gynecol Surv 1995;50:761.[Medline]
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