Factors Associated With Variation in Cesarean Rates

描述（由申请人提供）：剖宫产是一项大手术，与大多数外科手术一样，对母亲和婴儿都有健康风险。尽管美国卫生与公众服务部（DHHS）在《2000年健康人》和《2010年健康人》中建议减少剖宫产分娩的数量，但美国剖宫产分娩的数量从1970年的6%增加到2001年的近25%，从路易斯安那州的29.9%增加到犹他州的17.2% （Martin et al. 2002）。黑人妇女的剖宫产率高于白人和西班牙裔妇女，剖宫产率随年龄增长而增加，从20-24岁到35-39岁增加一倍。本研究有三个具体目的：(1)分析1990年至2002年国家医院出院调查（NHDS）的两年一次的数据，以检查剖宫产可能性的个体水平差异，包括患者特征、医院所有权、规模、地点和支付来源；(2)分析1990年和2002年两年期国家生命统计的出生数据，以检验不同聚集水平（即县、市、州和地区）剖宫产率的变化，以及患者组合和社区水平特征的随时间变化；(3)对在第一次访谈时处于妊娠晚期（周26左右）的妇女样本进行产前和产后调查，并与她们的产前保健提供者（如医生、产科医生或助产士）一起收集患者、提供者和医院层面的信息，这些信息将使我们能够对可能导致剖宫产的非临床（非产科）因素进行深入检查。我们将把医院和社区层面的信息附加到每个患者的调查数据中。这一阶段的研究将以医疗保健利用模型为指导（Andersen 1968）。这三个具体目标包括互补分析，检查同一研究问题的不同方面，并解决不同的研究问题。为了达到我们的分析目标，我们将使用描述性和多变量分析技术，如二元线性回归、多元回归、逻辑回归、多项Iogit回归和分层线性建模（或随机效应模型）。本研究的结果将有助于解释剖宫产率的时间和地理差异，并有助于我们理解与选择性剖宫产（即在没有临床指征的情况下）相关的多层次因素。

DESCRIPTION (provided by applicant): Cesarean section is major surgery, and as in most surgical procedures, there are health risks to both the mother and the baby. Despite the recommendation of the U.S. Department of Health and Human Services (DHHS) in Healthy People 2000, and in Healthy People 2010 to reduce the number of deliveries by cesarean section, the number of cesarean deliveries in the U.S. have increased from 6% of all deliveries in 1970 to nearly 25% in 2001 ranging from 29.9 in Louisiana to 17.2 in Utah (Martin et al. 2002). Cesarean rates were higher among black women than among white, and Hispanic women, and cesarean delivery rates increased with age, doubling from age 20-24 to age 35-39. The proposed research has three specific aims: (1) to analyze biennial data from the National Hospital Discharge Surveys (NHDS) from 1990 to 2002 to examine the individual-level variation in the likelihood of a cesarean delivery, by patient characteristics, hospital ownership, size, location, and payment source; (2) to analyze biennial Natality Data from the National Vital Statistics from 1990 and 2002 to examine the variation in cesarean rates across different levels of aggregation (i.e., county, city, state, and region), and over time by patient mix and community-level characteristics; and (3) to conduct a pre- and post-delivery survey with a sample of women who are in the third trimester (around the 26 the week) of their pregnancy at the first interview, and with their prenatal health care provider (e.g., physician, obstetrician, or midwife) to collect patient-, provider-, and hospital-level information that will allow us to conduct an in-depth examination of the non-clinical (non-obstetric) factors that might lead to a cesarean delivery. We will attach hospital-level and community-level information to each patient's survey data. This phase of the research will be a guided by a health care utilization model (Andersen 1968). The three specific aims comprise complementary analyses that examine different aspects of the same research problem and address different research questions. To attain our analytical objectives we will use descriptive and multivariate analysis techniques, such as, bivariate linear regression, multiple regression, logistic regression, multinomial Iogit regression, and hierarchical linear modeling (or random-effects model) as appropriate. The results from the proposed study will help explain the temporal and geographical variation in cesarean delivery rates, and contribute to our understanding of the multi-level factors associated with elective (i.e., in the absence of clinical indications) cesarean section.