{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,4]],"date-time":"2026-04-04T21:36:13Z","timestamp":1775338573436,"version":"3.50.1"},"reference-count":38,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2021,10,6]],"date-time":"2021-10-06T00:00:00Z","timestamp":1633478400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["BJOG"],"published-print":{"date-parts":[[2022,3]]},"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>To examine the association between county\u2010level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Cross\u2010sectional study.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>Population\u2010based study of US county\u2010level birth data from 2015 to 2017.<\/jats:p><\/jats:sec><jats:sec><jats:title>Population<\/jats:title><jats:p>Nulliparous women with term, singleton, vertex\u2010presenting infants (NTSV) at low risk for morbidity.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The primary exposure was county\u2010level CD rates.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main outcome measures<\/jats:title><jats:p>The outcome was morbidity among the low\u2010risk NTSV cohort, categorised as severe (5\u2010minute Apgar score of \u22643, assisted ventilation for \u22656\u2009hours, severe neurologic injury or seizure, transfer or death) or moderate (5\u2010minute Apgar score of &lt;7 but &gt;3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The analysis included data from 2\u2009753\u2009522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4\u201323.6) and 52.5 (IQR 33.4\u201375.7) per 1000 births, respectively. In the unadjusted analysis using the risk\u2010adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95%\u2009CI \u22120.9, \u22120.3) and 2.3 fewer (95%\u2009CI \u22123.4, \u22121.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Lower county\u2010level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA.<\/jats:p><\/jats:sec><jats:sec><jats:title>Tweetable abstract<\/jats:title><jats:p>Lower county\u2010level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.<\/jats:p><\/jats:sec>","DOI":"10.1111\/1471-0528.16925","type":"journal-article","created":{"date-parts":[[2021,9,17]],"date-time":"2021-09-17T08:09:00Z","timestamp":1631866140000},"page":"627-635","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Association between morbidity among term newborns and low\u2010risk caesarean delivery rates"],"prefix":"10.1111","volume":"129","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5568-4444","authenticated-orcid":false,"given":"MA","family":"Clapp","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology Massachusetts General Hospital Boston MA USA"},{"name":"Harvard Medical School Harvard University Boston MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"JR","family":"Daw","sequence":"additional","affiliation":[{"name":"Department of Health Policy &amp; Management Columbia University Mailman School of Public Health New York NY USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"KE","family":"James","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Massachusetts General Hospital Boston MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"SE","family":"Little","sequence":"additional","affiliation":[{"name":"Harvard Medical School Harvard University Boston MA USA"},{"name":"Department of Obstetrics and Gynecology Brigham and Women\u2019s Hospital Boston MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"JN","family":"Robinson","sequence":"additional","affiliation":[{"name":"Harvard Medical School Harvard University Boston MA USA"},{"name":"Department of Obstetrics and Gynecology Newton\u2010Wellesley Hospital Newton MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"SV","family":"Bates","sequence":"additional","affiliation":[{"name":"Harvard Medical School Harvard University Boston MA USA"},{"name":"Department of Pediatrics Massachusetts General Hospital Boston MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"AJ","family":"Kaimal","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Massachusetts General Hospital Boston MA USA"},{"name":"Harvard Medical School Harvard University Boston MA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2021,10,6]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1055\/s-0031-1285829"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2008.03.007"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.060870"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000219750.79480.84"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2012.1030"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.13592"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12978-015-0043-6"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2015.15553"},{"key":"e_1_2_7_10_1","first-page":"8","article-title":"A prediction model for severe maternal morbidity in laboring patients at term","volume":"36","author":"Rosenbloom JI","year":"2018","journal-title":"Am J Perinatol"},{"key":"e_1_2_7_11_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-018-2169-3"},{"key":"e_1_2_7_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2015.01.043"},{"key":"e_1_2_7_13_1","unstructured":"The Joint Commission.Specifications manual for Joint Commission national quality measures. PC\u201002 (v2021A1)[Internet].2020[https:\/\/manual.jointcommission.org\/releases\/TJC2021A1\/MIF0167.html]. Accessed 9 December 2020."},{"key":"e_1_2_7_14_1","unstructured":"National Quality Forum.Cesarean birth [Internet]. Quality Positioning System (QPS) measure description display information.2020[www.qualityforum.org]. Accessed 9 December 2020."},{"key":"e_1_2_7_15_1","unstructured":"California Maternal Quality Care Collaborative.NTSV cesarean birth overview[Internet] [www.cmqcc.org\/focus\u2010areas\/quality\u2010improvement\/ntsv\u2010c\u2010sections]. Accessed 9 December 2020."},{"key":"e_1_2_7_16_1","unstructured":"Centers for Disease Control and Prevention (CDC).Revisions of the U.S. standard certificates and reports[Internet]. National Center for Health Statistics.2017[www.cdc.gov\/nchs\/nvss\/revisions\u2010of\u2010the\u2010us\u2010standard\u2010certificates\u2010and\u2010reports.htm]. Accessed 11 April 2019."},{"key":"e_1_2_7_17_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.19498"},{"key":"e_1_2_7_18_1","unstructured":"The Joint Commission.Specifications manual for Joint Commission national quality measures[Internet]. Perinatal Care \u2013 PC\u201006 v2018B [https:\/\/manual.jointcommission.org\/releases\/TJC2018B\/MIF0393.html]. Accessed 16 May 2019."},{"key":"e_1_2_7_19_1","unstructured":"Small Area Health Insurance Estimates (SAHIE) Program[Internet] [www.census.gov\/programs\u2010surveys\/sahie.html]. Accessed 2 January 2020."},{"key":"e_1_2_7_20_1","unstructured":"US Department of Labor.Bureau of Labor Statistics. Databases tables & calculators by subject[Internet] [www.bls.gov\/data\/]. Accessed 23 February 2018."},{"key":"e_1_2_7_21_1","unstructured":"US Census Bureau.Current Population Survey (CPS) Data[Internet] [https:\/\/www.census.gov\/programs\u2010surveys\/cps.html]. Accessed 23 February 2018."},{"key":"e_1_2_7_22_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e3181d9f4b6"},{"key":"e_1_2_7_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2015.12.042"},{"key":"e_1_2_7_24_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2017.12.228"},{"key":"e_1_2_7_25_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2018.10.028"},{"key":"e_1_2_7_26_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0000000000003109"},{"key":"e_1_2_7_27_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.semperi.2006.07.002"},{"key":"e_1_2_7_28_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e31821e5f65"},{"key":"e_1_2_7_29_1","first-page":"1","article-title":"Trends in cesarean rates for first births and repeat cesarean rates for low\u2010risk women: United States, 1990\u20132003","volume":"54","author":"Menacker F","year":"2005","journal-title":"Natl Vital Stat Rep"},{"key":"e_1_2_7_30_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2014.01.026"},{"key":"e_1_2_7_31_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)31930-5"},{"key":"e_1_2_7_32_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2004.02.055"},{"key":"e_1_2_7_33_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2006.03.013"},{"key":"e_1_2_7_34_1","doi-asserted-by":"publisher","DOI":"10.1177\/003335491513000108"},{"key":"e_1_2_7_35_1","first-page":"1","article-title":"Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states","volume":"62","author":"Martin JA","year":"2013","journal-title":"Natl Vital Stat Rep"},{"key":"e_1_2_7_36_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annepidem.2005.03.005"},{"key":"e_1_2_7_37_1","first-page":"1","article-title":"Assessing the quality of medical and health data from the 2003 Birth certificate revision: results from New York City","volume":"68","author":"Gregory ECW","year":"2019","journal-title":"Natl Vital Stat Rep"},{"key":"e_1_2_7_38_1","first-page":"1","article-title":"Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states","volume":"62","author":"Martin JA","year":"2013","journal-title":"Natl Vital Stat Rep"},{"key":"e_1_2_7_39_1","doi-asserted-by":"publisher","DOI":"10.1023\/A:1019726112597"}],"container-title":["BJOG: An International Journal of Obstetrics &amp; Gynaecology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1471-0528.16925","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/1471-0528.16925","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1471-0528.16925","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,15]],"date-time":"2023-11-15T20:38:44Z","timestamp":1700080724000},"score":1,"resource":{"primary":{"URL":"https:\/\/obgyn.onlinelibrary.wiley.com\/doi\/10.1111\/1471-0528.16925"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,10,6]]},"references-count":38,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2022,3]]}},"alternative-id":["10.1111\/1471-0528.16925"],"URL":"https:\/\/doi.org\/10.1111\/1471-0528.16925","archive":["Portico"],"relation":{},"ISSN":["1470-0328","1471-0528"],"issn-type":[{"value":"1470-0328","type":"print"},{"value":"1471-0528","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,6]]},"assertion":[{"value":"2021-05-28","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2021-10-06","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}