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(Am J Obstet Gynecol 2017;217:474.e1–e5)Perinatal quality initiatives, including proposed national benchmarks for acceptable cesarean delivery rates, have aimed to design best practices to reduce cesarean delivery rates and obtain optimal outcomes for mothers and infants. However, whether all hospitals can be held to the same benchmark for an acceptable cesarean delivery rate regardless of patient acuity is debatable, and the reasons for between-hospital variation in cesarean rates are not clear. The aim of this study was to evaluate the association between the severity of illness at admission and the primary term singleton vertex (TSV) cesarean delivery rates in Washington State. The authors hypothesized that hospitals with higher patient acuity would have higher term TSV cesarean delivery rates and that this relationship would persist despite temporal trends.