{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T14:48:50Z","timestamp":1788792530415,"version":"build-2803163510"},"reference-count":39,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2022,4,7]],"date-time":"2022-04-07T00:00:00Z","timestamp":1649289600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Caesarean section (C-sections) is a medically critical and often life-saving procedure for prevention of childbirth complications. However, there are reports of its overuse, especially in women covered by private insurance as compared to public insurance. This study evaluates the difference in C-Section rates among nulliparous women in Florida hospitals across insurance groups and quantifies the contribution of maternal and hospital factors in explaining the difference in rates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We used Florida\u2019s inpatient data provided by the Florida Agency for HealthCare Administration (FLAHCA) and focused on low-risk births that occurred between January 1, 2010, and September 30, 2015. A Fairlie decomposition method was performed on cross-sectional data to decompose the difference in C-Section rates between insurance groups into the proportion explained versus unexplained by the differences in observable maternal and hospital factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of the 386,612 NTSV low-risk births, 72,984 were delivered via C-Section (18.87%). Higher prevalence of C-section at maternal level was associated with diabetes, hypertension, and the expectant mother being over 35 years old. Higher prevalence of C-section at the hospital level was associated with lower occupancy rate, presence of neonatal ICU (NICU) unit and higher obstetrics care level in the hospital. Private insurance coverage in expectant mothers is associated with C-section rates that were 4.4 percentage points higher as compared to that of public insurance. Just over 33.7% of the 4.4 percentage point difference in C-section rates between the two insurance groups can be accounted for by maternal and hospital factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The study identifies that the prevalence of C-sections in expectant mothers covered by private insurance is higher compared to mothers covered by public insurance. Although, majority of the difference in C-Section rates across insurance groups remains unexplained (around 66.3%), the main contributor that explains the other 33.7% is advancing maternal age and socioeconomic status of the expectant mother. Further investigation to explore additional factors that explain the difference needs to be done if United States wants to target specific policies to lower overall C-Section rate.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0266666","type":"journal-article","created":{"date-parts":[[2022,4,7]],"date-time":"2022-04-07T13:49:37Z","timestamp":1649339377000},"page":"e0266666","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":20,"title":["Estimating the differences in Caesarean section (C-section) rates between public and privately insured mothers in Florida: A decomposition approach"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8893-2317","authenticated-orcid":true,"given":"Neeraj","family":"Puro","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4053-056X","authenticated-orcid":true,"given":"Reena J.","family":"Kelly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mandar","family":"Bodas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Feyereisen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,4,7]]},"reference":[{"issue":"10155","key":"pone.0266666.ref001","doi-asserted-by":"crossref","first-page":"1341","DOI":"10.1016\/S0140-6736(18)31928-7","article-title":"Global epidemiology of use of and disparities in caesarean sections","volume":"392","author":"T Boerma","year":"2018","journal-title":"The Lancet"},{"issue":"1","key":"pone.0266666.ref002","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1186\/s12978-015-0043-6","article-title":"What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies","volume":"12","author":"AP Betran","year":"2015","journal-title":"Reproductive health"},{"key":"pone.0266666.ref003","author":"Connection C.","year":"2004"},{"issue":"18","key":"pone.0266666.ref004","doi-asserted-by":"crossref","first-page":"2411","DOI":"10.1001\/jama.283.18.2411","article-title":"Association between method of delivery and maternal rehospitalization","volume":"283","author":"M Lydon-Rochelle","year":"2000","journal-title":"Jama"},{"issue":"8","key":"pone.0266666.ref005","doi-asserted-by":"crossref","first-page":"e1910236","DOI":"10.1001\/jamanetworkopen.2019.10236","article-title":"Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring: a systematic review and meta-analysis","volume":"2","author":"T Zhang","year":"2019","journal-title":"JAMA network open"},{"issue":"Suppl1","key":"pone.0266666.ref006","doi-asserted-by":"crossref","first-page":"W355","DOI":"10.1377\/hlthaff.25.w355","article-title":"Geographic variation in the appropriate use of cesarean delivery: do higher usage rates reflect medically inappropriate use of this procedure?","volume":"25","author":"K Baicker","year":"2006","journal-title":"Health Affairs"},{"issue":"1","key":"pone.0266666.ref007","doi-asserted-by":"crossref","first-page":"123. e1","DOI":"10.1016\/j.ajog.2015.08.027","article-title":"Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida","volume":"214","author":"YV Sebasti\u00e3o","year":"2016","journal-title":"American journal of obstetrics and gynecology"},{"issue":"3","key":"pone.0266666.ref008","doi-asserted-by":"crossref","first-page":"e57817","DOI":"10.1371\/journal.pone.0057817","article-title":"Hospital differences in cesarean deliveries in Massachusetts (US) 2004\u20132006: the case against case-mix artifact","volume":"8","author":"IA Caceres","year":"2013","journal-title":"PloS one"},{"key":"pone.0266666.ref009","volume-title":"Seminars in perinatology","author":"H Minkoff","year":"2012"},{"issue":"6","key":"pone.0266666.ref010","first-page":"1352","article-title":"Risk factors for cesarean delivery at presentation of nulliparous patients in labor.","volume":"102","author":"PT Wilkes","year":"2003","journal-title":"Obstetrics & Gynecology"},{"issue":"1","key":"pone.0266666.ref011","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1007\/s10995-014-1498-8","article-title":"Determinants of cesarean delivery in the US: a lifecourse approach","volume":"19","author":"WP Witt","year":"2015","journal-title":"Maternal and child health journal"},{"issue":"8","key":"pone.0266666.ref012","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2017-016600","article-title":"Caesarean sections and private insurance: systematic review and meta-analysis","volume":"7","author":"I Hoxha","year":"2017","journal-title":"BMJ open"},{"issue":"1","key":"pone.0266666.ref013","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1080\/10796126.2016.1254601","article-title":"Examining the association between Medicaid coverage and preterm births using 2010\u20132013 National Vital Statistics Birth Data","volume":"23","author":"AR Markus","year":"2017","journal-title":"Journal of Children and Poverty"},{"key":"pone.0266666.ref014","volume-title":"The cost of having a baby in the United States","author":"MP Corry","year":"2013"},{"issue":"4","key":"pone.0266666.ref015","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1016\/S0167-6296(99)00009-0","article-title":"Physician fees and procedure intensity: the case of cesarean delivery","volume":"18","author":"J Gruber","year":"1999","journal-title":"Journal of health economics"},{"issue":"10","key":"pone.0266666.ref016","doi-asserted-by":"crossref","first-page":"e1001745","DOI":"10.1371\/journal.pmed.1001745","article-title":"Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database","volume":"11","author":"KB Kozhimannil","year":"2014","journal-title":"PLoS Med"},{"key":"pone.0266666.ref017","unstructured":"Services USDoHH. The Surgeon General\u2019s Call to Action to Improve Maternal Health 2020 [Available from: https:\/\/www.hhs.gov\/sites\/default\/files\/call-to-action-maternal-health.pdf."},{"key":"pone.0266666.ref018","article-title":"Variation in the rate of cesarean section across US hospitals, 2013: statistical brief# 211","author":"K Mistry","year":"2016"},{"issue":"1","key":"pone.0266666.ref019","doi-asserted-by":"crossref","first-page":"B2","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":"J Armstrong","year":"2017","journal-title":"American journal of obstetrics and gynecology"},{"issue":"5","key":"pone.0266666.ref020","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1177\/1062860617753063","article-title":"Area deprivation index predicts readmission risk at an urban teaching hospital","volume":"33","author":"J Hu","year":"2018","journal-title":"American Journal of Medical Quality"},{"issue":"7","key":"pone.0266666.ref021","doi-asserted-by":"crossref","first-page":"904","DOI":"10.1038\/s41372-019-0373-2","article-title":"Hospital contribution to variation in rates of vaginal birth after cesarean","volume":"39","author":"JE Triebwasser","year":"2019","journal-title":"Journal of Perinatology"},{"issue":"4","key":"pone.0266666.ref022","doi-asserted-by":"crossref","first-page":"305","DOI":"10.3233\/JEM-2005-0259","article-title":"An extension of the Blinder-Oaxaca decomposition technique to logit and probit models","volume":"30","author":"RW Fairlie","year":"2005","journal-title":"Journal of economic and social measurement"},{"issue":"2","key":"pone.0266666.ref023","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1007\/s13524-011-0089-1","article-title":"Black-white disparities in life expectancy: how much can the standard SES variables explain?","volume":"49","author":"M. Geruso","year":"2012","journal-title":"Demography"},{"issue":"3","key":"pone.0266666.ref024","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1002\/hec.1715","article-title":"What is driving the black\u2013white difference in low birthweight in the US?","volume":"21","author":"A Lhila","year":"2012","journal-title":"Health Economics"},{"issue":"4","key":"pone.0266666.ref025","first-page":"455","article-title":"Maternal country of birth differences in breastfeeding at hospital discharge in Ireland","volume":"45","author":"A Brick","year":"2014","journal-title":"The Economic and Social Review"},{"issue":"1","key":"pone.0266666.ref026","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12913-016-1494-3","article-title":"Differences in nulliparous caesarean section rates across models of care: a decomposition analysis","volume":"16","author":"A Brick","year":"2016","journal-title":"BMC health services research"},{"issue":"4","key":"pone.0266666.ref027","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1111\/ppe.12484","article-title":"Differences in caesarean rates across women\u2019s socio\u2010economic status by diverse obstetric indications: Cross\u2010sectional study","volume":"32","author":"K Adhikari","year":"2018","journal-title":"Paediatric and perinatal epidemiology."},{"issue":"3","key":"pone.0266666.ref028","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1111\/j.1523-536X.2010.00409.x","article-title":"Advanced maternal age and the risk of cesarean birth: a systematic review","volume":"37","author":"H Bayrampour","year":"2010","journal-title":"Birth"},{"issue":"6","key":"pone.0266666.ref029","doi-asserted-by":"crossref","first-page":"1202","DOI":"10.1007\/s10995-014-1624-7","article-title":"Maternal age and risk of labor and delivery complications","volume":"19","author":"PA Cavazos-Rehg","year":"2015","journal-title":"Maternal and child health journal"},{"issue":"2","key":"pone.0266666.ref030","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1111\/aogs.13265","article-title":"Maternal body mass index as a predictor for delivery method","volume":"97","author":"A Pettersen\u2010Dahl","year":"2018","journal-title":"Acta obstetricia et gynecologica Scandinavica."},{"issue":"18","key":"pone.0266666.ref031","doi-asserted-by":"crossref","first-page":"1930","DOI":"10.1001\/jama.2013.3982","article-title":"Elective cesarean delivery on maternal request","volume":"309","author":"J. Ecker","year":"2013","journal-title":"Jama"},{"key":"pone.0266666.ref032","article-title":"Diagnosis and unnecessary procedure use: Evidence from c-section","author":"J Currie","year":"2013"},{"issue":"3","key":"pone.0266666.ref033","doi-asserted-by":"crossref","first-page":"e212235","DOI":"10.1001\/jamanetworkopen.2021.2235","article-title":"Evaluation of Hospital Cesarean Delivery\u2013Related Profits and Rates in the United States","volume":"4","author":"R Sakai-Bizmark","year":"2021","journal-title":"JAMA Network Open"},{"key":"pone.0266666.ref034","article-title":"Maternal and neonatal effects of caesarean section","author":"A Shorten","year":"2007","journal-title":"British Medical Journal Publishing Group"},{"issue":"6","key":"pone.0266666.ref035","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1097\/GCO.0b013e328332d1b0","article-title":"New perinatal quality measures from the National Quality Forum, the Joint Commission and the Leapfrog Group","volume":"21","author":"EK Main","year":"2009","journal-title":"Current Opinion in Obstetrics and Gynecology"},{"issue":"6","key":"pone.0266666.ref036","doi-asserted-by":"crossref","first-page":"1185","DOI":"10.1377\/hlthaff.2011.0358","article-title":"How Intermountain trimmed health care costs through robust quality improvement efforts","volume":"30","author":"BC James","year":"2011","journal-title":"Health Affairs"},{"key":"pone.0266666.ref037","unstructured":"(AHCA) AfHCA. AHCA and FDOH Recognize 19 Hospitals in Florida for Achieving the Healthy People 2020 Low-risk, Primary C-section Goal 2019 [Available from: http:\/\/www.floridahealth.gov\/newsroom\/2019\/10\/102519-ahca-and-fdoh-recognize-19-hospitals-in-florida-for-achieving-the-healthy-people-2020-lowrisk-primary-csection-goal.pr.html."},{"key":"pone.0266666.ref038","unstructured":"Fund TC. State Policies to Improve Maternal Health Outcomes 2020 [Available from: https:\/\/www.commonwealthfund.org\/publications\/maps-and-interactives\/2020\/nov\/state-policies-improve-maternal-health-outcomes."},{"issue":"2","key":"pone.0266666.ref039","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/0091-2182(94)90016-7","article-title":"Cesarean section rates in low-risk private patients managed by certified nurse-midwives and obstetricians","volume":"39","author":"LG Davis","year":"1994","journal-title":"Journal of Nurse-Midwifery"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0266666","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,4,7]],"date-time":"2022-04-07T13:49:59Z","timestamp":1649339399000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0266666"}},"subtitle":[],"editor":[{"given":"M. Mahmud","family":"Khan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2022,4,7]]},"references-count":39,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2022,4,7]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0266666","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,4,7]]}}}