Trends in Obstetric Operative Procedures, 1980 to 1987

S. Christine Zahniser, RN, MPH, Juliette S. Kendnck, MD, Adele L. Franks, MD, and Audrey F. Saftilas, PhD

Introduction Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. In 1987, cesarean deliveries became the most frequently performed surgical procedure among women of childbearing years.' Some researchers have hypothesized that this increase in cesarean sections is the result of a decrease in the use of forceps.2 However, limited information has been published on the national trends of other operative obstetric procedures occurring during deliveries.3 Here, we examine US trends in the use of forceps, vacuum extraction, and cesarean section over an 8-year period. In addition, we present the demographic characteristics of women most likely to receive these interventions.

Methods We analyzed data from the National Hospital Discharge Survey, conducted by the National Center for Health Statistics. Each year, a representative sample of discharges is selected from approximately 400 short-term-stay, nonfederal hospitals throughout the United States.4 About 200 000 abstracts of medical records are sampled annually. Data are transcribed from the face sheet of the medical record to the National Hospital Discharge Survey abstract form. Abstracted items include demographic characteristics of the patient, administrative information, expected sources of payment, up to seven discharge diagnoses, and up to four procedures. Coding is performed according to the Intenational Classifica-

tion of Diseases, 9th revision, Clinical Modification (ICD-9-CM).5 We restricted our analysis to women hospitalized for a delivery (ICD-9-CM codes V27.0 through V27.9) from 1980 through 1987. The obstetric procedures we analyzed included the use of forceps (ICD-9-CM codes 72.0 through 72.49, 72.51, 72.53, 72.6, 73.3), vacuum extraction (72.7), and cesarean sections (74.0 through 74.29, 74.4, 74.99). For each delivery, we selected only one operative procedure code, even if more were present. For example, in the many cases in which both low forceps use (72.0) and forceps rotation of the fetal head (72.4) were recorded, we analyzed this combination as one forceps procedure. We classified the mother's race as "White" or "Black and other minorities." Insurance status was established on the basis of information collected from patients at admission to the hospital. Women whose expected source of payment included any type of private or commercial insurance were reported as having "private insurance." Women who reported self-payment or government payment, including Medicaid/Medicare, were considered to have "no private inS. Christine Zahniser, Juliette S. Kendrick, and Audrey F. Saftlas are with the Division of Reproductive Health, and Adele L. Franks is with the Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Ga. Requests for reprints should be sent to S. Christine Zahniser, RN, MPH, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, GA 30333. This paper was submitted to the Journal October 28, 1991, and accepted with revisions May 19, 1992.

October 1992, Vol. 82, No. 10

Obstetric Operative Procdures

surance." Women in the "other" payment group, which consisted of those in the "workman's compensation," "no charge," or "other" payment categories, represented less than 5% of the sample and were excluded from the analysis of insurance data. Rate ratio analyses of the 1987 deliveries were conducted to identify women at increased risk of having the various procedures. We used the computer program SESUDAAN (Rearch Triangle Institute, Research Triangle Park, NC) to calculate rates and their corresponding standard errors,6 andwe took into account the complex multistage sampling design of the National Hospital Discharge Survey. We used the Taylor series expwansion with the logot transformation to calculate 95% confidence intervals on rate ratios.7 Weighted linear regression was used to test for linear trend in the rates of various procelures over the 8-year study period.8 Rates and rate ratios are provided only for procedrs with 5000 or more discharges; estimates of less than 5000 in the National Hospital Discharge Survey are considered statistically unreliable? since they are based on fewer than 30 records. We calculated crude and adjusted rates of cesarean section, forceps, and vacuum extraction procedures for 1987. Because the age- and race-adjusted rates were simiar to the crude rates, we present only the crude rates here.

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FIGURE 1-Rate of US obsc operatie procedures, 1980 to 1987, National Hospal Discharge Survey, Naional Centr for Health Statistics, Hyasville, Md.

in 1980 (Figure 1). Between 1980 and 1987,

Resiuts General Trends

cesarean sections increased by 48% (from 617 000 to 949 000), whereas forceps pro-

The number of operative delivery procedures, including cesarean sections, forceps, and vacuum extraction procedures, increased from 1.2 million in 1980 to 1.4 million in 1987, affecting 35.8% of all deliveries in 1987, compared with 31.3%

cedures declined by 43% (from 539 000 to 320 000). In comparison, vacuum extraction procedures increased from 0.6% to 3.3% of all deliveries (from 22 000 to 122 000); most of this increase occurred after 1983.

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Trends in obstetric operative procedures, 1980 to 1987.

Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical...
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