Medicaid-Covered C-sections Pose Higher Risk of Infection

By Megan Headley

In recent years, evidence has shown that women with Medicaid coverage are more prone to a range of health risks during and following pregnancy, including chronic conditions and higher risks of mortality. Now a new study indicates that Medicaid-insured women face higher rates of surgical site infections (SSI) following cesarean section delivery than privately insured women.

The Centers for Disease Control and Prevention (CDC) study, “Surgical Site Infection Risk Following Cesarean Deliveries Covered by Medicaid or Private Insurance,” was published in April in Infection Control & Hospital Epidemiology, the journal for the Society for Healthcare Epidemiology of America.

Researchers found that women who delivered via C-section and were covered by Medicaid had a 1.4-fold increase in infections compared to those covered by private insurance.

“The findings force researchers to look beyond the usual suspects behind surgical site infections,” comments CDC health scientist Sarah Yi, PhD, lead author of the study. “More investigation is needed to determine why women with Medicaid health insurance had a much greater burden of surgical site infections after cesarean delivery than privately insured women.”

One-third of births in the United States occur by C-section. In 2014, about 40% of U.S. C-section births were covered by Medicaid. Yi says that previous studies have shown lower rates of C-section deliveries among women covered by Medicaid compared with those covered by private insurance.

Of course, C-sections come with unique risks, including risk of SSI. Previous CDC studies had suggested differential risk of SSI by payer following C-sections, Yi explains. “A larger, multicenter study was needed to verify this signal.”

Yi and her fellow researchers dug into linked data from the CDC’s National Healthcare Safety Network and state inpatient discharges to identify SSIs in the 30 days following C-section, examining a pool of 291,757 C-section deliveries in California from 2011 to 2013. Forty-eight percent of these deliveries were covered by Medicaid. According to the CDC, this is the largest study thus far to examine the role of health insurance coverage in the risk of SSI following U.S. C-section deliveries.

The researchers found SSIs were detected in 1,055 deliveries (0.75%) covered by Medicaid and in 955 deliveries (0.63%) covered by private insurance. The evidence also indicated that these infections were more frequently detected during post-discharge surveillance and hospital readmission than during the original hospitalization. Risk of SSI during the original hospitalization was small and did not differ by payer type.

The researchers note in the paper that the increased risk may stem from a combination of factors, including patient, provider, facility, and state policy factors.  Examples could include patient health literacy, patient living situation, and available social support following hospital discharge, as well as payer-driven differences in healthcare provision. Additionally, ensuring readiness for discharge and providing adequate discharge education may be important interventions to improve outcomes among patients with social, economic, and other vulnerabilities.

But Yi urges caution in interpreting the data. “While we do see a signal that women with Medicaid coverage have increased risk of SSI compared with those covered by private insurance, we can only speculate on potential reasons why,” she says. “For any patient receiving surgery, in-hospital education on warning signs and symptoms of an SSI would be important. Ultimately, though, it’s beyond the scope of this study to pinpoint the particular problem(s) causing the difference in SSI risk by payer.”

Researchers note the study may have been limited by the lack of information on post-discharge surveillance methods. Due to data limitations, researchers were unable to account for other potential confounders, including marital status, repeated pregnancy loss, duration of insurance coverage, and prenatal and postnatal care. Thus, Yi says, a multidisciplinary approach is the best way to build a story on the association between these risks and a potential cause.

“Subject matter experts in disciplines such as health policy, patient safety, obstetrics and surgical care, and healthcare epidemiology would be crucial to the development of a list of important research questions. Methodologists across these disciplines would be essential to the design of strong, efficient studies to investigate these questions,” Yi says.

But the evidence emphatically suggests that to inform targeted infection prevention efforts, hospitals serving vulnerable patient groups need to evaluate their maternal healthcare for women covered by Medicaid.

Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at