Fear in the Delivery Room: A Predictive Model of How Medical Liability, Midwifery Care, and Reproductive Education Affect Cesarean Section Rates in the United States

Abstract

The United States has one of the highest cesarean section delivery rates in the world, yet distribution of cesarean section rates for U.S. counties vary drastically. This research presents a model which identifies counties with a cesarean section delivery rate level for first-born singleton births of greater than 30%. The research presents the role of fear as a determinant for cesarean delivery rates. The proposed model includes three main drivers of cesarean section deliveries: fear of litigation, maternal fear of childbirth, and broader structural forces. Birth data from 2012 are analyzed, along with county demographics data, medical liability premiums, midwifery care, and reproductive education for 511 counties within the United States. Logistic univariate analysis identified high maternal age, low gestational age, high rate of diabetes, high medical liability premiums, lack of reproductive education, lack of support for midwifery care, census region, rural/urban classification, and high levels of income inequality as significantly associated with high cesarean section rates, for first-birth singleton deliveries at the county level. Data was split into training/sample and test/out-of-sample sets and multivariable logistic regression analysis was used to develop a predictive model on the sample set to accurately identify counties with a high cesarean section rate in the test/out-of-sample data set. The model accurately predicted 72% of records. The results suggest that fear of litigation on behalf of the provider and a maternal fear of childbirth influence the rate of cesarean section deliveries at the county level.

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