{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T16:02:08Z","timestamp":1790870528632,"version":"4.1.0"},"reference-count":26,"publisher":"American Medical Association (AMA)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n The Society for Maternal-Fetal Medicine (SMFM) low-risk cesarean delivery metric aims to improve comparability, but the extent to which additional patient-level adjustment and reliability profiling alter hospital rankings is not well characterized.<\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n To evaluate how hospital cesarean delivery rankings differ across overall, SMFM-defined low-risk, and reliability-adjusted low-risk approaches, and to identify hospital characteristics associated with reliability-adjusted low-risk rates.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This cross-sectional study used data from the 2022 National Inpatient Sample, a nationally representative all-payer database, on individuals aged 11 to 55 years who were hospitalized for childbirth. Data were analyzed from October 2025 through June 2026.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Hospital cesarean delivery rates and rankings based on overall births, SMFM low-risk births (unadjusted), and empirical bayesian reliability-adjusted SMFM low-risk rates (mixed-effects logistic regression adjusting for age and obstetric comorbidities). Concordance was summarized by quartile cross-classification. Hospitals were classified as as-expected, lower-than-expected, or higher-than-expected on the basis of the 95% credible interval for the reliability-adjusted rate relative to the overall mean, and a hospital-level multivariable regression assessed characteristics associated with that rate.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Of the 330\u202f977 SMFM low-risk deliveries (mean [SD] maternal age, 29.0 [5.7] years) across 1231 hospitals, 45\u202f471 (13.7%) were cesarean. Mean (SD) hospital cesarean delivery rates were 32.1% (5.4%) for overall cesarean delivery, 13.5% (4.2%) for SMFM low-risk cesarean delivery, and 10.4% (2.4%) for reliability-adjusted SMFM low-risk cesarean delivery. Quartile concordance between overall and unadjusted SMFM low-risk rankings was modest (61.7% agreement in the lowest quartile), whereas concordance between SMFM low-risk and reliability-adjusted rankings was higher (85.7% agreement in the lowest quartile). Based on 95% credible intervals, 1024 hospitals (83.2%) were classified as having as-expected rates of cesarean delivery, 81 (6.6%) as having lower-than-expected rates of cesarean delivery, and 126 (10.2%) as having higher-than-expected rates of cesarean delivery. In multivariable analysis, Midwestern (\u03b2\u2009=\u2009\u22121.13 percentage points; 95% CI, \u22121.56 to \u22120.70 percentage points) and Western (\u03b2\u2009=\u2009\u22121.26 percentage points; 95% CI, \u22121.68 to \u22120.83 percentage points) hospitals had lower reliability-adjusted rates than Northeastern hospitals.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this cross-sectional study of US hospitals, cesarean delivery rankings differed substantially between overall and SMFM low-risk denominators, highlighting limitations of overall rates for accountability. The high concordance between unadjusted and reliability-adjusted rankings suggests that the SMFM low-risk metric already captures most of the between-hospital signal. US region was the strongest correlate of reliability-adjusted rates.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.37167","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T15:45:41Z","timestamp":1790869541000},"page":"e2637167","source":"Crossref","is-referenced-by-count":0,"title":["Hospital Cesarean Delivery Rankings by Overall, Low-Risk, and Reliability-Adjusted Metrics"],"prefix":"10.1001","volume":"9","author":[{"given":"Tetsuya","family":"Kawakita","sequence":"first","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia"},{"name":"EVMS Center for Maternal and Child Health Equity and Advocacy, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Regan N.","family":"Theiler","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"George","family":"Saade","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences Eastern Virginia Medical School at Old Dominion University, Norfolk, Virginia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"issue":"2","key":"zoi260998r1","first-page":"1","article-title":"Births: final data for 2022.","volume":"73","author":"Osterman","year":"2024","journal-title":"Natl Vital Stat Rep"},{"issue":"6","key":"zoi260998r2","doi-asserted-by":"publisher","first-page":"684.e1","DOI":"10.1016\/j.ajog.2023.06.016","article-title":"Assessing hospital differences in low-risk cesarean delivery metrics in Florida.","volume":"229","author":"Obure","year":"2023","journal-title":"Am J Obstet Gynecol"},{"issue":"2","key":"zoi260998r3","doi-asserted-by":"publisher","first-page":"235","DOI":"10.1097\/AOG.0000000000004645","article-title":"Variations in low-risk cesarean delivery rates in the United States using the Society for Maternal-Fetal Medicine definition.","volume":"139","author":"Ouyang","year":"2022","journal-title":"Obstet Gynecol"},{"issue":"2","key":"zoi260998r4","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1016\/j.ajog.2015.10.935","article-title":"Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures.","volume":"214","author":"Armstrong","year":"2016","journal-title":"Am J Obstet Gynecol"},{"issue":"24","key":"zoi260998r5","doi-asserted-by":"publisher","first-page":"1968","DOI":"10.1001\/jama.279.24.1968","article-title":"Impact of risk-adjusting cesarean delivery rates when reporting hospital performance.","volume":"279","author":"Aron","year":"1998","journal-title":"JAMA"},{"key":"zoi260998r6","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2017.04.013","article-title":"Coding update of the SMFM definition of low risk for cesarean delivery from ICD-9-CM to ICD-10-CM.","volume":"217","author":"Armstrong","year":"2017","journal-title":"Am J Obstet Gynecol"},{"issue":"3","key":"zoi260998r7","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.5428","article-title":"Cesarean delivery trends among patients at low risk for cesarean delivery in the US, 2000-2019.","volume":"6","author":"Frappaolo","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"2","key":"zoi260998r8","doi-asserted-by":"publisher","first-page":"B2","DOI":"10.1016\/j.ajog.2021.10.007","article-title":"Society for Maternal-Fetal Medicine special statement: a quality metric for evaluating timely treatment of severe hypertension.","volume":"226","author":"Combs","year":"2022","journal-title":"Am J Obstet Gynecol"},{"issue":"15","key":"zoi260998r9","doi-asserted-by":"publisher","first-page":"1531","DOI":"10.1001\/jama.2014.13381","article-title":"Association between hospital-level obstetric quality indicators and maternal and neonatal morbidity.","volume":"312","author":"Howell","year":"2014","journal-title":"JAMA"},{"issue":"9596","key":"zoi260998r11","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.","volume":"370","author":"von Elm","year":"2007","journal-title":"Lancet"},{"issue":"2 Pt 1","key":"zoi260998r12","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1097\/AOG.0b013e31824323d9","article-title":"Hospital volume, provider volume, and complications after childbirth in U.S. hospitals.","volume":"119","author":"Illuzzi","year":"2012","journal-title":"Obstet Gynecol"},{"issue":"12","key":"zoi260998r13","doi-asserted-by":"publisher","first-page":"1277","DOI":"10.1001\/jama.2009.1356","article-title":"Evaluating obstetrical residency programs using patient outcomes.","volume":"302","author":"Asch","year":"2009","journal-title":"JAMA"},{"issue":"10","key":"zoi260998r14","doi-asserted-by":"publisher","first-page":"e561","DOI":"10.1542\/neo.20-10-e561","article-title":"Maternal mortality in the United States: updates on trends, causes, and solutions.","volume":"20","author":"Collier","year":"2019","journal-title":"Neoreviews"},{"issue":"3","key":"zoi260998r15","doi-asserted-by":"publisher","first-page":"440","DOI":"10.1097\/AOG.0000000000004022","article-title":"An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.","volume":"136","author":"Leonard","year":"2020","journal-title":"Obstet Gynecol"},{"issue":"10","key":"zoi260998r17","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.38604","article-title":"Association of maternal comorbidity burden with cesarean birth rate among nulliparous, term, singleton, vertex pregnancies.","volume":"6","author":"Wetcher","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"12","key":"zoi260998r18","first-page":"700","article-title":"Interpreting estimates of treatment effects: implications for managed care.","volume":"33","author":"Faraone","year":"2008","journal-title":"P&T"},{"issue":"1","key":"zoi260998r19","doi-asserted-by":"crossref","first-page":"29","DOI":"10.3102\/10769986014001029","article-title":"Empirical Bayes ranking methods.","volume":"14","author":"Laird","year":"1989","journal-title":"J Educ Stat"},{"issue":"3","key":"zoi260998r20","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1016\/j.athoracsur.2014.11.039","article-title":"A primer on using shrinkage to compare in-hospital mortality between centers.","volume":"99","author":"MacKenzie","year":"2015","journal-title":"Ann Thorac Surg"},{"issue":"1","key":"zoi260998r21","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jvs.2010.08.031","article-title":"The impact of adjusting for reliability on hospital quality rankings in vascular surgery.","volume":"53","author":"Osborne","year":"2011","journal-title":"J Vasc Surg"},{"issue":"4","key":"zoi260998r22","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1177\/1062860614534461","article-title":"Hospital variations in severe sepsis mortality.","volume":"30","author":"Wang","year":"2015","journal-title":"Am J Med Qual"},{"issue":"2","key":"zoi260998r23","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1093\/intqhc\/mzh035","article-title":"Risk Adjustment for Measuring Health Care Outcomes, 3rd edition.","volume":"16","author":"Thomas","year":"2004","journal-title":"Int J Qual Health Care"},{"issue":"12","key":"zoi260998r24","doi-asserted-by":"crossref","first-page":"2234","DOI":"10.1080\/14767058.2020.1783229","article-title":"Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data.","volume":"35","author":"Friedman","year":"2022","journal-title":"J Matern Fetal Neonatal Med"},{"issue":"4","key":"zoi260998r25","doi-asserted-by":"crossref","first-page":"506","DOI":"10.1097\/EDE.0000000000001743","article-title":"Validation of ICD-10 codes for severe maternal morbidity at delivery in a public hospital.","volume":"35","author":"Boulet","year":"2024","journal-title":"Epidemiology"},{"issue":"11","key":"zoi260998r26","doi-asserted-by":"crossref","first-page":"1288","DOI":"10.1111\/aogs.13006","article-title":"Validation of hospital discharge diagnoses for hypertensive disorders of pregnancy.","volume":"95","author":"Luef","year":"2016","journal-title":"Acta Obstet Gynecol Scand"},{"key":"zoi260998r10","unstructured":"HCUP-US NIS overview. Healthcare Cost and Utilization Project. Accessed April 13, 2026. https:\/\/hcup-us.ahrq.gov\/nisoverview.jsp"},{"key":"zoi260998r16","unstructured":"Obstetric comorbidity scoring system. California Maternal Quality Care Collaborative. Accessed February 2, 2026. https:\/\/www.cmqcc.org\/education-research\/severe-maternal-morbidity\/obstetric-comorbidity-scoring-system"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2854695\/kawakita_2026_oi_260998_1790261818.65544.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T15:45:44Z","timestamp":1790869544000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2854695"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,1]]},"references-count":26,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2026,10,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2026.37167","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,1]]}}}