Graduation Year


Document Type




Degree Granting Department

Community and Family Health

Major Professor

Elizabeth Gulitz, Ph.D.

Co-Major Professor

Hamisu M. Salihu, M.D., Ph.D.

Committee Member

Donna J. Petersen Sc.D.

Committee Member

Charles S. Mahan, M.D.

Committee Member

William M. Sappenfield, M.D.


Preterm Birth, Cesarean, Infant Morbidity, Maternal Morbidity


There are increasing concerns about the excessive use of cesarean delivery in the United States, as cesarean deliveries have been associated with adverse maternal and infant health outcomes. Currently, the cesarean section (C/S) rate for Florida is the second highest in the nation. Furthermore, preliminary reports from the Florida Department of Health (FDOH) have implicated the increasing rate of cesarean delivery to an increase in the rate of late preterm births (PTB) in Florida (births at 34 to 36 weeks gestational age). Information on the impact of late PTB associated with cesarean delivery on the rate of maternal and infant morbidity in Florida as well as corresponding utilization of health care services is scarce. Information on the validity of data sources used to investigate infant and maternal health outcomes in Florida is also scarce. Therefore, the objectives of this research project were: (1) to determine the validity of data sources used to investigate low documented risk C/S and late PTB, and (2) to assess the impact of low documented risk C/S on maternal and infant morbidity and subsequent healthcare utilization. To determine the accuracy of data elements reported on the Florida birth certificate and hospital discharge data, sensitivity, specificity, positive predictive value, negative predictive value, kappa statistics and likelihood ratios were calculated. To assess differences in morbidity by route of delivery, generalized estimating equations and survival analyses were employed. Markov Chain Monte Carlo methods were used to determine appropriate morbidities for inclusion in all analyses. Differences in accuracy of data by data source was observed, with linked birth certificate and hospital discharge data demonstrating improved accuracy compared to birth certificate and discharge data alone. Further, significant differences in the rate of maternal and infant morbidity by route of delivery were observed, with cesarean delivery increasing the risk of adverse health outcomes, and intensive use of healthcare services.