What hospitals don’t want you to know about C-sections
The procedures drive up costs and increase risks for mothers & babies, a Consumer Reports’ investigation finds
Pregnant women put a lot of trust in their doctors and hospitals. But a Consumer Reports investigation of more than 1,500 hospitals in 22 states suggests that such trust may be misplaced. It found that in many hospitals, far too many babies enter this world through cesarean section.
While some C-sections are absolutely necessary for the health of the mother or baby, the high C-section rates in our low-scoring hospitals are “unsupportable by professional guidelines and studies of birth outcomes,” said Elliot Main, M.D., director of the California Maternal Quality Care Collaborative and former chairman of the department of obstetrics and gynecology at the California Paci c Medical Center in San Francisco, who reviewed our data.
Our Ratings reveal that C-section rates vary dramatically— even between neighboring hospitals. For example, almost 55 percent of pregnant women anticipating low-risk deliveries—that is, women who haven’t had a C-section before, don’t deliver prematurely, and are pregnant with a single baby who is properly positioned—nonetheless undergo a C-section at Los Angeles Community Hospital. But at California Hospital Medical Center, also in Los Angeles, the rate of C-sections for low-risk deliveries is 15 percent; at Western Medical Center Anaheim, 28 miles away, it’s about 11 percent.
Or consider El Paso, Texas. At Sierra Medical Center, 37 percent of low-risk deliveries are C-sections; four miles away at University Medical Center of El Paso the rate is about 15 percent. It’s a similar story in Colorado.Denver Health Medical Center earned a top score with a C-section rate of about 8 percent, while nearby Presbyterian-St. Luke’s Medical Center got low marks for a rate of about 20 percent.
We found this startling scenario playing out over and over in communities large and small across the U.S. Because a hospital’s C-section rate can be hard to find, it’s likely that most families are unaware of the huge differences in medical practice. And
unfortunately, it’s usually much easier to find a hospital with a high C-section rate than a low one. Overall, 66 percent of the hospitals in our Ratings earned our lowest or second-lowest score, while only 12 percent got either of our top two marks.
“We think it’s time those hidden numbers are brought to light,” said John Santa, M.D., medical director of Consumer Reports Health. “How you deliver your baby should be determined by the safest delivery method, not which hospital you choose.”
Change is already afoot. Evidence on the fallout from too many C-sections has grown so alarming that numerous health organizations have made lowering rates a priority. In March 2014, two major women’s health organizations—the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) —teamed to publish groundbreaking new practice guidelines aimed at preventing unnecessary cesarean births.
But hospitals can be bureaucratic institutions where the wheels of change move slowly. We’ll look at why C-sections remain so overused. And our Ratings—the most comprehensive ever on C-sections for individual U.S. hospitals—can help families choose the right place to deliver their baby.
The health risks of unnecessary C-sections
ere are times when a surgical birth is the safest option. For example, C-sections can be lifesaving when the outlet from the womb is blocked by the placenta (a condition called placenta previa) or the baby isn’t properly positioned for birth by, for example, lying sideways in the uterus instead of head down. And with modern obstetrical care, C-sections are quite safe.
But a C-section—the second most commonly performed surgical procedure in the country, requiring a 6-inch incision in the abdomen
and a second through the uterus—is major surgery, and thus takes longer to recover from than a vaginal delivery and also carries additional risks.
“C-sections increase the risk of mortality and complications,” says Kent Heyborne, M.D., chief of obstetrics at Denver Health Medical Center, which had the lowest C-section rate of any hospital in our Ratings with at least 5,000 low-risk deliveries over the two-year period included in our analysis. “But we’re just now becoming aware of the down stream effects.”
Carol Sakala, Ph.D., director of Childbirth Connection programs at the National Partnership for Women & Families, agrees. “Unless there is a definitive need for a C-section, vaginal birth has major benefits for moms and babies, both in the short term and throughout the course of their lives,” she said.
To begin with, although having a C-section may sound like a shortcut, it’s not. Speros says that although her C-sections went smoothly, it still took much longer to recover from them than it did from the vaginal birth of her third son.
And like others who’ve had abdominal surgery, she has lingering numbness at the site of the incision. Nineteen percent of women who’ve had a C-section report pain at the incision site being a major problem in the two months following delivery. That’s according to Listening to Mothers III, a national survey conducted by Harris
Cutting the number of C-sections in half would save the U.S. about $5 billion a year in health care costs.
Interactive for the Childbirth Connection of 2,400 mothers who gave birth to single babies in a hospital from July 2011 through June 2012. at compares with 11 percent of women who gave birth vaginally who cited a painful perineum (the area between the vagina and anus) as a major problem. And women with C-sections were more likely to say that the pain lasted six months or longer, too.
Life-threatening complications are rare whether babies are born vaginally or by C-section. But compared with women giving birth vaginally, healthy, low-risk women undergoing their first C-section were three times more likely to suffer serious complications—such as severe bleeding, blood clots, heart attack, kidney failure, and infections—according to a 14-year analysis of more than 2 million women in Canada published in 2007 and cited by the new ACOG/SMFM guidelines.
And the risk of complications increases with each subsequent cesarean delivery. “Once you’ve had a C-section, there’s a big chance that all future births will also be by cesarean,” Main said. “And that’s when the risks really start to rise.”
Vaginal delivery for uncomplicated births is also better for babies. They are less likely to suffer breathing problems and more likely to be breastfed, perhaps because it’s easier to get breastfeeding going when mothers are not recovering from major surgery. Some research suggests that over the long-term, babies born vaginally may be slightly less prone to chronic ailments such as asthma, allergies, or obesity, perhaps due in part to a protective effect from beneficial bacteria transferred from the mother during birth.
Why C-section rates are so high
The number of C-sections performed in the U.S. has leveled off in the last few years, but is still up 500 percent since 1970. All those C-sections have not translated into substantially better outcomes for mothers and babies. The infant death rate in the U.S., while low, is higher than that of most other industrialized nations. And the maternal death rate actually increased slightly from 1990 to 2013, according to an analysis published May 2, 2014, online in The Lancet medical journal.
In part those grim statistics reflect the fact that American women today tend to be older and heavier going into pregnancy. But experts say that the main problem is a health care system that no longer values normal birth and focuses on scheduling labor, in part for patient and doctor convenience.
In the U.S. far fewer babies are born on holidays such as the Fourth of July or days around Thanksgiving or Christmas, we found when we examined three year’s worth of data on births compiled for us by the Centers for Disease Control and Prevention. That could be because hospitals tend to schedule C-sections for times when they are well staffed—or because doctors, and even some mothers, may not want deliveries to interrupt their holidays.
That level of control requires increased use of interventions such as inducing, or starting, labor before a woman’s due date, which might increase the risk of cesarean delivery, or just scheduling a C-section from the start.
Another major problem is that many doctors intervene because they think that labor is moving too slowly and that longer labors lead to complications. But those assumptions are based on outdated information, says Aaron Caughey, M.D., Ph.D., chair of the department of obstetrics and gynecology and associate dean for women’s health research and policy at Oregon Health and Science University in Portland, Ore., and lead author on the new ACOG/SMFM guidelines.
The new guidelines help clear up when providers should act and when they have to be patient and let nature take its course. The absence of solid, up-to-date guidelines might have allowed other factors, including concerns about malpractice suits, to drive up the number of C-sections, Caughey says.
In addition, hospitals keeping watch on their financial bottom lines may turn a blind eye to high C-section rates. Medicaid and private health insurance pay about 50 percent more for C-sections than for vaginal births. Halving the total number of C-sections performed in the U.S. would save about $5 billion yearly, according to the Center for Healthcare Quality & Payment Reform, which advocates for higher-quality, lower-cost health care.
What our ratings show
Our Ratings are based on the C-section rates for mothers who anticipate low-risk deliveries—that is, for women who haven’t had a C-section before, don’t deliver prematurely, and are pregnant with a single baby who is properly positioned. While complications such as
Moms who deliver a first baby by C-section are about 90 percent more likely to deliver their second baby that way, too.
major problems with the baby’s heartbeat could happen during labor and require intervening surgically, experts say that the vast majority of women in that low-risk category should be able to have a vaginal birth.
The average C-section rate for low-risk deliveries among the hospitals we looked at was about 18 percent—much higher than the national average of 12.6 percent in 2000, a benchmark we used to develop our Ratings. (Note that the average total C-section rate, which includes all cesarean deliveries not just low-risk ones, is 33 percent.)
And some hospitals performed much better—or worse— than average. C-section rates ranged from less than 5 percent at Saint Croix Regional Medical Center in Saint Croix Falls, Wis., to a high of almost 57 percent at Three Rivers Medical Center in Louisa, Ky.
So why do some hospitals have higher rates than others?
Unfortunately, we found no simple answers. Prospect Medical Holdings, the company that owns Los Angeles Community Hospital, says it treats “a significantly higher percentage of low-income and transient patients, many of whom have had little or no prenatal or primary care prior to delivery.” Those women may be at higher risk because of gestational diabetes or high blood pressure, a representative told us.
Our analysis did find slightly higher rates at hospitals in large urban areas compared with hospitals in smaller cities, perhaps because they see more women with risk factors not accounted for in our data or they have a larger proportion of first-time moms. But many similar hospitals serving similar populations manage to keep C-section rates low. For example, Saint Anthony Hospital in Chicago treats many low-income patients but still earned a high Rating, with a C-section rate of 9 percent of babies.
Our Ratings also confirm findings from other research showing significant regional differences. The lowest rates were in mountain states, the West coast, and the upper Midwest. For-profit hospitals also tended to have higher C-section rates.
But none of those factors come close to explaining the wide variation we found, the experts we consulted say.
Don’t blame mothers
Too often the medical establishment blames mothers. “They must be older, fatter, sicker, or they must be requesting C-sections,” Main said. “But that’s completely bogus. As a doctor I can convince almost any woman in labor to have a C-section.” Even after you account for things such as mothers’ age and weight, according to Main, you are still left with huge discrepancies of care.
Almost two-thirds of women in the Listening to Mothers survey who had their first C-section said their doctor was the decision maker, and more than one-quarter said they felt pressured to have the surgery.
“What it boils down to is culture,” Main said. “Culture of the hospital, the nursing staff, even the patients.” He points out that hospitals with a culture of facilitating vaginal birth—those that allow vaginal birth after cesarean, for example, or those where 10 percent or more of births are attended by nurse midwives—have far lower rates of C-sections.
A culture such as the one you find at Denver Health Medical Center, where Heyborne works. Lots of places say they have an “institutional philosophy” against too many C-sections, says Heyborne, but, “It’s how we’ve translated that into action that makes a difference.” He says that as a teaching hospital, Denver Health is fully staffed with health care providers 24/7. “A lot of C-sections are done at 5 or 6 in the evening,” Heyborne said. “We don’t have those pressures here. No one is trying to get home to dinner or the golf course.”
In addition he says that the hospital has firm policies against using interventions that might lead to cesareans, such as inducing labor without a medical reason. And Heyborne credits an active midwifery service. “About one-third of our births are managed by midwives and that helps keep the emphasis on natural birth processes.”
How we rate hospitals: Avoiding C-sections
The Ratings are based on the C-section rates for mothers who anticipate a low-risk delivery—that is, women who haven’t had a C-section before, don’t deliver prematurely, and are pregnant with a single baby who is the proper position for delivery. The Ratings include all mothers, not just first-time mothers. The data the Ratings are based on do not include information on factors that may increase the risk for a C-section, such as heart problems in the mother or fetus, pregnancy-related high blood pressure, diabetes, obesity, or any other chronic disease.
The data come from the 22 states that had data available for us to analyze: Arizona, California, Colorado, Florida, Iowa, Illinois, Kentucky, Massachusetts, Maryland, North Carolina, New Jersey, New York, Nevada, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Virginia, Vermont, Washington, and Wisconsin.
It covers births during a two-year period between 2009 and 2012, depending on the state. We include hospitals with a minimum of 100 low-risk deliveries over that two-year period.
Hospitals with high or low C-section rates
The table below shows the 10 hospitals in our Ratings with the lowest C-section rates that had at least 5,000 low-risk deliveries over two years.
The table below shows the 10 hospitals in our Ratings with the highest C-section rates that had at least 5,000 low-risk deliveries over two years.
What you can do to avoid C-sections
To lower your risk of a C-section, take the following steps.
- Find out your hospital’s C-section rate. Start with our hospital Ratings. If your hospital is not included, ask the person who will deliver your baby about the hospital’s rates. Remember: lower is usually better. The average national C-section rate for low-risk deliveries, the measure used in our Ratings, is about 18 percent, a rate we consider too high. A more reasonable figure is 12.6 percent, the national average in 2000 and a benchmark we used to develop our Ratings. (Note that the average total C-section rate, which includes all cesarean deliveries not just low-risk ones, is 33 percent.)
- Choose your provider carefully. It’s good to know the C-section rates for your doctor, too, so ask whether his or her practice tracks their C-sections. “Even if they don’t know the exact percent, providers should be able to articulate their philosophy about supporting vaginal birth,” Caughey said. Also ask how the new ACOG/SMFM guidelines may affect the practice’s approach to labor and delivery. If your provider is unaware of the new standards, or is dismissive of them, you may want to find a different one.
- Watch your weight. If you are overweight, strive to shed excess pounds before becoming pregnant. Overweight and obese women have a much higher risk of C-section than normal weight women. And once you’re pregnant, talk with your provider about the healthy weight gain for you. Women who are overweight should plan to gain less than those who are not.
- Stay fit. Women who take part in structured exercise during pregnancy are less likely to need a C-section, research suggests. Talk to your health care provider about appropriate forms of exercise, such as walking, swimming, and aerobic or yoga classes for pregnant women.
- Don’t rush things. Doctors should not try to induce labor unless there’s a good medical reason—for example, if a woman’s membranes rupture (her “water breaks”) and labor doesn’t start on its own or she is two weeks overdue. Trying to induce labor before a woman’s body is ready can lead to surgical delivery if labor doesn’t progress.
- Don’t worry too much about big babies. The possibility of a large baby is frequently used to justify a cesarean delivery, but that’s not warranted, according to the new ACOG/SMFM guidelines. To begin with, methods used to assess the baby’s weight toward the end of the pregnancy are not very accurate. Also, babies typically have to be 11 pounds or larger to justify a C-section, according to Caughey.
- Get support during labor. Consider hiring a doula, a trained birth assistant who can provide physical and emotional support throughout labor and delivery. Women who have continuous support from someone who is not a friend, family member, or a member of the hospital staff labor for shorter periods and are less likely to need interventions, research shows. Ask your insurer if it will cover doula care.
- Ignore the clock. The new ACOG/SMFM guidelines call for allowing more time in each phase of labor and delivery. In general, decisions on whether to intervene should be based on how well mothers and babies are doing, not how much time has passed.
For additional steps you can take before and during pregnancy to help ensure the best possible outcomes, see our report “What to Reject When You’re Expecting” here: consumerhealthchoices.org/wp-content/uploads/2013/04/ ExpectRejectGeneral.pdf
And see these additional resources:
- American College of Obstetricians and Gynecologists Patient Resources – www.acog.org/Patients
- American College of Nurse Midwives Patient Resources – www.midwife.org/Share-With-Women
- Childbirth Connection – www.childbirthconnection.org
- March of Dimes Pregnancy – www.marchofdimes.com
- March of Dimes Nacer Sano – nacersano.marchofdimes.com
- Office of Women’s Health Pregnancy Resources – www.womenshealth.gov/pregnancy
What to do if you need a C-sections
Sometimes a planned C-section is the safest option for you and your baby. And even if you’ve planned for a vaginal birth, complications may arise that necessitate a surgical delivery. All expectant families should discuss cesarean deliveries with their provider so that they understand what’s involved and are not caught off guard. Thee following steps can help ensure a safe, satisfying birth experience for you and your family.
- Be wary of early C-sections. Babies’ delivered before 39 weeks are more apt to have breathing problems or other issues. C-sections should not be scheduled before that point unless there’s a valid medical reason.
- Discuss your preferences. Ask if a birthing partner can be with you in the surgery room and recovery area. When will you be able to hold and breastfeed your baby? Skin-to-skin contact between moms and babies right after delivery facilitates bonding and breastfeeding.
- Ask for antibiotics at the time of surgery. That reduces the risk of infection. You don’t need them afterward unless you develop an infection.
- Ask that your uterus be closed with two layers of stitching. If you decide to have another baby vaginally, so called double-layering stitching will hold more securely during labor and delivery.
- Request measures to prevent blood clots. That might include wearing inflatable devices on your legs until you can walk on your own or taking a prescription blood thinner. Ask the nursing staff to help you get up and move around as soon as you are able to do so.
- Ask for help breastfeeding. Getting started breastfeeding as you recover poses extra challenges. A lactation consultant can provide invaluable support and advice.
- Marshal support. Plan to have extra support at home so you can focus on recovering and getting to know your new baby.
Find your hospital's C-section rates
We have rated more than 1,500 hospitals in 22 states on their C-section rates for low-risk deliveries—that is, women who haven’t had a C-section before, don’t deliver prematurely, and are pregnant with a single baby who is properly positioned. Those states are: Arizona, California, Colorado, Florida, Iowa, Illinois, Kentucky, Massachusetts, Maryland, North Carolina, New Jersey, New York, Nevada, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Virginia, Vermont, Washington, and Wisconsin. You can download a PDF of the Avoiding C-section Ratings for all 22 states by going to: www.consumerreports.org/csectionratings
A Mother’s Story
Melek Speros of Austin, Texas, says her doctor warned her late in her first pregnancy that her pelvis might be too small to allow for a vaginal delivery.“I was really surprised because I’m 5’8” tall with a large frame,” Speros said. Reluctantly, her doctor agreed to allow her to “try” a vaginal birth by inducing labor eight days before her due date at St. David’s South Austin Medical Center (which earned low marks in our Ratings.) When the induction didn’t quickly work, he recommended a C-section.“He said that a vaginal birth would be unsafe, that my baby could get stuck and suffer serious harm,” Speros said.
She took him at his word, and delivered her first son by C-section as well as her second son two years later. That’s no surprise: Mothers who deliver a first baby by C-section are about 90 percent more likely to deliver subsequent babies that way, too. But with her third, in what she describes as “the culmination of my hopes and dreams about giving birth,” Speros vaginally delivered a healthy 9-pound boy.
Speros’ experience—feeling pressured into a C-section without being informed about her birthing options— prompted her to change career plans, switching from lawyer to childbirth educator. And indeed getting reliable information about how hospitals approach childbirth can be difficult. For example, while hospitals often target expectant mothers with ads featuring cherubic infants and cozy birthing rooms, they seldom publicize their rates for surgical deliveries.
More than a quarter of women in a ‘Listening to Mothers’ survey who had a first C-section said they felt pressured to have the surgery.