Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample



We sought to determine if hospital delivery volume was associated with a patient’s risk for cesarean delivery in low-risk women.

Study Design:

This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal–Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient’s odds for cesarean delivery.


The range of cesarean delivery rates was 2.4–51.2% among low-risk patients, and the median was 16.5% (IQR 12.8–20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient’s odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188).


Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type



Prices may be subject to local taxes which are calculated during checkout

Figure 1


  1. Podulka J, Stranges E, Steiner C Hospitalizations Related to Childbirth, 2008: Statistical Brief #110 In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality: Rockville, MD, USA, 2006..

  2. Bailit JL, Gregory KD, Srinivas S, Westover T, Grobman WA, Saade GR . Society for Maternal-Fetal Medicine (SMFM) Special Report: current approaches to measuring quality of care in obstetrics. Am J Obstet Gynecol 2016; 215 (3): B8–16.

    Article  Google Scholar 

  3. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR . Preventing the first 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. Obstet Gynecol 2012; 120 (5): 1181–1193.

    PubMed  PubMed Central  Google Scholar 

  4. Bailit J, Garrett J . Comparison of risk-adjustment methodologies for cesarean delivery rates. Obstet Gynecol 2003; 102 (1): 45–51.

    PubMed  Google Scholar 

  5. Bailit JL, Love TE, Dawson NV . Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J Obstet Gynecol 2006; 194 (2): 402–407.

    Article  Google Scholar 

  6. Main EK, Moore D, Farrell B, Schimmel LD, Altman RJ, Abrahams C et al. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol 2006; 194 (6):1644–1651 discussion 1651–2.

    Article  Google Scholar 

  7. Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK Society for Maternal-Fetal Medicine Health Policy Committee. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol 2016; 214 (2): 153–163.

    Article  Google Scholar 

  8. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL . Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349 (22): 2117–2127.

    Article  CAS  Google Scholar 

  9. Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346 (15): 1128–1137.

    Article  Google Scholar 

  10. Morche J, Mathes T, Pieper D . Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev 2016; 5 (1): 204.

    Article  Google Scholar 

  11. Finks JF, Osborne NH, Birkmeyer JD . Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011; 364 (22): 2128–2137.

    Article  CAS  Google Scholar 

  12. Bach PB, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB . The influence of hospital volume on survival after resection for lung cancer. N Engl J Med 2001; 345 (3): 181–188.

    Article  CAS  Google Scholar 

  13. Clapp MA, Melamed A, Robinson JN, Shah N, Little SE . Obstetrician volume as a potentially modifiable risk factor for cesarean delivery. Obstet Gynecol 2014; 124 (4): 697–703.

    Article  Google Scholar 

  14. Sebastião YV, Womack L, Vamos CA, Louis JM, Olaoye F, Caragan T et al. Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida. Am J Obstet Gynecol 2016; 214 (1): 123.e1–123.e18.

    Article  Google Scholar 

  15. Coonrod DV, Drachman D, Hobson P, Manriquez M . Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors. Am J Obstet Gynecol 2008; 198: 694.e1–11 discussion 694.e11.

    Article  Google Scholar 

  16. Kozhimannil KB, Hung P, Prasad S, Casey M, McClellan M, Moscovice IS . Birth volume and the quality of obstetric care in rural hospitals. J Rural Health 2014; 30 (4): 335–343.

    Article  Google Scholar 

  17. Agency for Healthcare Research and QualityHealthcare Cost and Utilization Project: Nationwide Readmissions Database (cited 22 November 2016). Available at (accessed 2016).

  18. Kuklina EV, Whiteman MK, Hillis SD, Jamieson DJ, Meikle SF, Posner SF et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J 2008; 12 (4): 469–477.

    Article  Google Scholar 

  19. Kozhimannil KB, Law MR, Virnig BA . Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff Proj Hope 2013; 32 (3): 527–535.

    Article  Google Scholar 

  20. Little SE, Orav EJ, Robinson JN, Caughey AB, Jha AK . The relationship between variations in cesarean delivery and regional health care use in the United States. Am J Obstet Gynecol 2016; 214 (6): 735.e18.

    Article  Google Scholar 

  21. Clapp MA, Little SE, Zheng J, Robinson JN . A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol 2016; 215 (1): 113.e1–113.e10.

    Article  Google Scholar 

  22. Agency for Healthcare Research and Quality. HCUP-US NIS Overview (cited 18 January 2017). Available at

  23. US Department of Health and Human ServicesBirths: Final Data for 2013 (cited 2017 Jan 18), vol 64, no 1. Available at (accessed January 2015) p 65.

Download references


We acknowledge the AHRQ’s HCUP Data Partners that contributed data to the Nationwide Readmissions Database: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin and Wyoming.

Author information

Authors and Affiliations


Corresponding author

Correspondence to M A Clapp.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Clapp, M., James, K., Melamed, A. et al. Hospital volume and cesarean delivery among low-risk women in a nationwide sample. J Perinatol 38, 127–131 (2018).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


Quick links