Geospatial distribution of relative cesarean section rates within the USA

To evaluate the existence of statistically significant clusters of Cesarean section rates at the county level and assess the relationship of such clusters with previously implicated socioeconomic factors.

County-level obstetrics data was extracted from March of Dimes, originally sourced from National Center for Health Statistics. County-level demographic data were extracted from the US Census Bureau. Access to obstetricians was extracted from National Provider Identifier records. Rural counties were identified using Rural Urban Commuting Area codes developed by the department of agriculture. The dataset was geospatially analyzed using Moran's I statistic, a metric of local spatial autocorrelation, to identify clusters of increased or decreased Cesarean section rates. The American South, especially the Deep South, is a major cluster of increased Cesarean section rates. As a general but not absolute pattern, the American West and Midwest had lower Cesarean section rates than the Northeast. Focal areas of increased Cesarean section rates included the Kansas-Nebraska border, Michigan's upper peninsula, and the New York City metropolitan area. The gross geospatial differences were not explained by rurality, obstetric access, or ethnic and racial factors alone.