Association between type of health insurance and elective cesarean deliveries: New Jersey, 2004-2007

Objectives. I examined the relationship between insurance coverage, which may influence physician incentives and maternal choices, and cesarean delivery before labor. Methods. I analyzed hospital discharge data for mothers without previous cesarean deliveries in New Jersey between 2004 and 2007, with adjustment for maternal age, race, marital status, and maternal, fetal, and placental conditions. Results. Nearly 1 in 7 women (13.9%) had a cesarean delivery without laboring. Insurance status was strongly associated with cesarean birth. Women insured by Medicaid (adjusted relative risk [ARR]=0.88; 95% confidence interval [CI]=0.84, 0.91) or self-paying (ARR=0.81; 95% CI=0.78, 0.85) had a significantly lower likelihood, and women insured by BlueCross (ARR=1.06; 95% CI=1.03, 1.09) or standard commercial plans (ARR=1.06; 95% CI=1.02, 1.10) had a significantly higher likelihood of cesarean delivery than did women insured by commercial health maintenance organizations. These associations persisted in subsets restricted to lower-risk women and in qualitative sensitivity analyses for a hypothetical single, binary, unmeasured confounder. Conclusions. Insurance status has a small, independent impact on whether a woman without a previous cesarean delivery proceeds to labor or has a cesarean delivery without labor.