Trends in hospital-based childbirth care: The role of health insurance

Objectives: Childbirth is the leading reason for hospitalization in the United States, and maternityrelated expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care. Study Designs: Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals. Methods: Data on 6,717,486 hospital-based births for the years 2002 through 2009 came from the NIS. We used generalized estimating equations to measure associations over time between primary payer (Medicaid, private insurance, or self) and cesarean delivery, vaginal birth after cesarean (VBAC), labor induction, and episiotomy. Results: Controlling for clinical, demographic, and hospital factors, births covered by Medicaid had lower odds of cesarean delivery (adjusted odds ratio [AOR], 0.91), labor induction (AOR, 0.73), and episiotomy (AOR, 0.62) and higher odds of VBAC (AOR, 1.20; P <.001 for all AORs) compared with privately insured births. Cesarean rates increased 6% annually among births paid by private insurance (AOR, 1.06; P <.001) and less rapidly (5% annually) among those covered by Medicaid. Conclusions: US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US ospitals.