Your Biggest C-Section Risk May Be Your Hospital
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The most common major surgery performed in the U.S isn’t to remove an appendix or replace a knee. It’s to deliver babies by cesarean section, or C-section.
Roughly one out of every three babies born in this country—or about 1.3 million children each year—are delivered this way, instead of vaginally. Yet the vast majority of women prefer to deliver vaginally, according to a January 2017 study in the journal Birth.
So what’s going on?
While being overweight, diabetic, or older can make it more likely for a woman to have a C-section, the biggest risk factor is “the hospital a mother walks into to deliver her baby, and how busy it is,” says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in the U.S. and around the world.
A new Consumer Reports investigation of more than 1,300 hospitals across the U.S. echoes Shah’s findings. It reveals that C-section rates for low-risk deliveries in the U.S. vary dramatically from hospital to hospital, even between those located in the same communities.
When a C-Section Is Necessary
Sometimes, a C-section is absolutely necessary for a safe delivery, according to the American Congress of Obstetricians and Gynecologists (ACOG).
For example, an emergency C-section can be lifesaving if the placenta blocks the cervix, a condition called placenta previa. And it can sometimes make sense to schedule a C-section when, for example, the fetus isn’t properly positioned for birth. Cesareans can also be necessary if the mother has uncontrolled high blood pressure or diabetes, or when she is pregnant with twins, triplets, or other multiples.
But for most pregnancies, which are low-risk, C-sections are not necessary: Researchers estimate that almost half of the C-sections performed in the U.S. are not required. And performing a surgical birth can pose added risks to the mother and her child and also raise costs, research shows.
While many medical institutions across the U.S. are now taking steps to reduce unnecessary C-sections, women themselves can take steps to reduce their own risk of having one, including through their choice of hospital. A study in the journal Birth, for example, found that more than half of women said they would travel 20 miles farther to have their baby at a hospital with a C-section rate that was 20 percentage points lower.
“Women understand that the quality of care differs depending on the hospital they pick, and this study shows that it is possible for women, if properly armed with data, to vote with their feet and send a signal to the medical community by choosing—if possible—a hospital with a lower C-section rate,” explains Doris Peter, Ph.D., director of the Consumer Reports Health Ratings Center.
That said, some women may not have the option to choose a different hospital. (For more on what else you can do to reduce your risk of a C-section, see “How to Cut Your Odds of Having a C-Section.”) Reducing C-section risk for women is ultimately the responsibility of hospitals and providers, Peter says. And progress is being made in the medical community.
For example, ACOG and the Society for Maternal-Fetal Medicine (SMFM)—the nation’s two leading medical organizations that focus on childbirth—issued recommendations in 2014 aimed at safely reining in unnecessary C-sections. And new ACOG recommendations released earlier this year discourage the types of medical interventions in low-risk deliveries that can increase the risk of a C-section.
“No one is saying that C-sections are never necessary, and no woman should feel bad if they end up needing one,” says Elliott Main, M.D., the medical director of the California Maternal Quality Care Collaborative, a nonprofit organization that works to improve outcomes for mothers and babies. “The goal is to better support women in labor so that indications for C-sections do not develop,” he says.
The Danger of Unnecessary C-Sections
When C-sections aren’t medically indicated, they may be more likely to harm mothers and babies than to help them.
“As the cesarean rate went up from 1995 to 2007, we didn’t see a decrease in neonatal mortality in our country related to cesarean birth,” says Aaron B. Caughey, M.D., chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine in Portland and a lead author of the 2014 ACOG/SMFM recommendations. “In fact, if anything, we started to see an increase in maternal mortality.”
Harvard’s Shah points out that C-sections are major surgery, with all of the risks of any hospital procedure. “Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis [a life-threatening complication of certain infections] to hemorrhage to organ injury,” he says. The challenge is identifying the ones that aren’t necessary and implementing measures to stop them from occurring.
Life-threatening complications are very rare whether babies are born vaginally or by C-section. But women with low-risk pregnancies undergoing their first C-section were three times more likely to die or suffer serious complications—such as blood clots, heart attack, and major infections—compared with women delivering vaginally, according to a 14-year analysis of more than 2 million women in Canada published in 2007 and cited by the ACOG guidelines.
More on Pregnancy & Childbirth
Another reason to avoid a medically unnecessary C-section: It multiplies the chance that a woman’s future births will also be delivered that way. “Right now in the U.S., if you get a C-section the first time, you have a 90 percent chance of getting another one the second time,” Shah says.
And that's why efforts to reduce C-sections focus especially on preventing primary, or first-time, C-sections, Caughey adds.
And while some people may assume that C-sections are easier on mothers than vaginal births, it usually takes women longer to recover after a cesarean.
Vaginal delivery for low-risk pregnancies may also be 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.
Finally, C-sections cost almost 30 percent more than vaginal births. The average cost for a C-section in the U.S. today is $16,038, compared with $12,560 for a vaginal birth. The cost for any delivery can vary by as much as $10,000 across the U.S., according to Guroo.com, a nonprofit organization that publishes healthcare cost data.
Most Hospitals Do Too Many C-Sections
Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk for a cesarean: Pregnant women expecting just one child (not twins, triplets, or other multiples) and whose baby is full-term and is positioned head first—the position least likely to require a C-section.
The most recently available average C-section rate for those births is 25.8 percent. That's above the national target for low-risk births of 23.9 percent set by the Department of Health and Human Services. Main says that “almost all hospitals should be able to achieve a rate under 24 percent, and some hospitals should be able to aim even lower."
“Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non–medically indicated cesareans being done,” Caughey says. “That’s not good medicine.”
Yet, nearly six in 10 of the hospitals we looked at had C-section rates above 23.9 percent, the national target for low-risk births.
C-Sections Much More Common in Some States
The risk of having a C-section also varied depending on where in the U.S. women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest.
For example, four states had C-section rates of 30 percent or higher: West Virginia (31 percent), Florida (31 percent), Louisiana (32 percent), and Nebraska (34 percent—in the one Nebraska hospital reporting data). And four states had rates below 18.5 percent: South Dakota (17 percent), Idaho (17 percent), New Mexico (17 percent), and Minnesota (18 percent).
What Hospitals Say
The differences between C-section rates among individual hospitals for first-time, low-risk deliveries is even more dramatic than at the state level. For large hospitals, they ranged from 7 percent at Crouse Hospital in Syracuse, N.Y., to 51 percent at South Miami Hospital in Miami.
At Hialeah Hospital, outside of Miami, 64.6 percent of low-risk babies are delivered by cesarean.
Patricia Vila, a spokeswoman for Hialeah Hospital, told Consumer Reports that their hospital has been “focused on providing the appropriate services to our patients based on their clinical needs” and reviews delivery data with their OBs to make them aware of practice patterns.
Even though Hialeah’s C-section rate has crept down slightly (from 68 percent in last year’s report), it remains the highest in the country among all the hospitals in CR's ratings.
We found big differences in the rate of C-sections performed throughout the country—even among hospitals in the same community and in the same network. For example, within the TriHealth network in Cincinnati, Good Samaritan's C-section rate for low-risk deliveries was 28 percent, while Bethesda North Hospital, a little under 20 miles away, has a rate of 18 percent.
A spokesperson for the TriHealth network in Cincinnati said Good Samaritan Hospital delivers more children than any other hospital in Cincinnati and takes the highest-risk first-time mothers, including women with pre-existing heart disease, diabetes, other medical complications, no prenatal care, or significant poverty. According to the hospital spokesperson, many of those high-risk women end up at Good Samaritan after being transferred from another local hospital.
In our analysis, however, we found hospitals that say they treat a patient population similar to that of Good Samaritan, but have low C-section rates. For example, SSM St. Mary’s Health Center in Saint Louis, Mo., which says it treats a high-risk population, has a very low C-section rate (12 percent) for first-time moms with low-risk births, and received CR’s top rating.
SSM St. Mary's employs three midwives who work alongside the medical staff team to deliver more than 3,000 babies a year and makes it a priority to keep the cesarean rate low without compromising safety, says Gilad Gross, M.D., medical director of labor and delivery and postpartum services at the hospital.
“We feel it’s really important to prevent the first C-section so we can set the mom up for lifelong healthy reproduction,” Gross says. “We have a commitment to vaginal delivery: We don’t necessarily end induction at a certain time, we stick to published guidelines, we don’t let the time of day affect what we do, and we’re not afraid to take a little bit more time during a labor if everything is looking good.”
In another example of variation between nearby hospitals, 34 percent of low-risk deliveries at the Baylor All Saints Medical Center at Fort Worth in Texas were by C-section, while at JPS Health Network, less than 2 miles away, the rate was only 18 percent.
Baylor All Saints Medical Center (part of the Baylor Scott & White Health system) in Fort Worth, which received CR’s worst rating, said in a statement that improving their quality measures, including lowering their C-section rates, “is a top priority.” They have formed a task force “dedicated to reviewing C-section rates and developing tactics for improvement,” including giving individual physicians their rates and posting all rates for internal review. A spokesperson said the hospital’s own most recent data shows its low-risk C-section rate is now down to 30.7 percent.
JPS Health Network, which receives CR’s top rating, says that while they care for a challenging, high-risk population with more Medicaid patients and more medical problems than those of most other hospitals, they focus on individual patients when deciding when a C-section is really needed.
“We take the financial piece out of it, the politics out of it, and look at what’s the best thing for the patient when she comes into the hospital to give birth,” says Pat Alridge, R.N., executive director for women’s services. Alridge also says that, unlike some hospitals, JPS has OBs on the delivery floor 24-hours a day.
Large U.S. Hospitals With the Highest C-Section Rates
There were 216 hospitals in the U.S. with C-section rates above 33.3 percent for low-risk deliveries, earning these hospitals CR’s worst rating. The chart belows show the 22 largest of those hospitals—including 10 that got our worst rating on C-sections last year, too.
Reducing the rate of C-sections at these large hospitals would have the biggest impact in terms of lowering the number of C-sections performed. (Many large hospitals don’t report their rates at at all, however, making it impossible to compare them to their peers.)
Large U.S. Hospitals With the Lowest C-Section Rates
There were 203 hospitals in the U.S. with C-section rates for low-risk deliveries of 18.4 percent or lower, earning these hospitals CR’s best rating. Twenty-two of them were hospitals that delivered a high volume of babies in a year.
Why C-Section Rates Are So High
Much of the conventional wisdom for why rates have increased points to mothers—but that conventional wisdom doesn’t bear out, Shah says.
“Some people say moms are older, there’s more diabetes, there’s more hypertension, there’s more obesity, there’s more IVF [in-vitro fertilization], there’s more twins—but all of that collectively only explains a small amount of the increase over time," he says.
Neither does patient demand appear to be behind the rates. Less than 1 percent of women actually asked for a C-section without a medical reason for it, according to a survey of 1,314 new mothers conducted by Childbirth Connection, part of the nonprofit National Partnership for Women and Families. Of the 252 women in that survey who had a C-section, only one had requested it without a medical reason.
The use of continuous fetal heart monitoring—which can create anxiety about non-emergencies—and doctors’ perceptions of prolonged labor (and when it’s appropriate to intervene) are two of the biggest contributors to increased C-section rates for low-risk deliveries, Shah explains. “Those are where we see the most variation and discretion in the decision to do the C-section, where there’s the most room for interpretation from the physician,” he says.
Heart-rate monitors appeared in the early 1970s with the promise of decreasing newborn deaths by tracking the baby’s heart rate in real time, but the only thing they do in low-risk births is “reliably increase the C-section rate,” he says. That’s because monitors only accurately identify a real problem about 15 percent of time. “It’s really low, so that means most of the time, you’re overreacting."
And labor dystocia—the technical term for prolonged labor—can be in the eyes of the beholder. Some providers may intervene because they think labor is moving too slowly and that longer labors lead to complications, says Amy Romano, a certified nurse midwife (CNM) and senior vice president of clinical programs for Baby+Company, a network of midwife-led maternity clinics based in North Carolina. But those assumptions about how long labor should take are based on information gathered in the 1950s.
ACOG earlier this year released guidelines to help clear up when healthcare providers should act and when they should be patient and let labor take its course, though Caughey doesn't expect practices to change immediately. “Changing that takes time,” he notes. “That appears to be starting to happen, but will be a slow transformation."
Add to that the pressure that can occur when the delivery floor gets unexpectedly busy, and even well-intentioned doctors can end up rushing a birth to free up beds, especially if the staff is short-handed. “It can be really, really quiet, and then an hour later it’s like a bus pulls up and drops off 10 pregnant women,” Shah says. “The environment around them makes it harder to do the right thing—fewer staff, fewer beds, more patients.”
In the U.S., far fewer babies are born on holidays such as the Fourth of July or days around Thanksgiving or Christmas, Consumer Reports found when we examined three years' worth of data on births compiled for us by the Centers for Disease Control and Prevention. That occurs partly because hospitals tend to schedule C-sections and inductions for when they are well staffed, during the week, Shah explained.
But nature’s timeline cannot be predicted: If a woman shows up Christmas Eve in labor, the fact that so few staff are working could increase her likelihood of delivering a cesarean birth.
How Hospitals Can Improve
Lowering C-section rates can take years of hard work, according to Robert Silverman, M.D., chief of the Department of Obstetrics and Gynecology at Crouse Hospital in Syracuse, N.Y. His hospital had the lowest C-section rate in our ratings for low-risk pregnancies among hospitals with at least 3,500 births, at just 7 percent.
"We have spent literally decades on educating the physicians at our institution about really good prenatal care," Silverman says. "Everything we can do to prevent that first C-section from occurring, we try to do."
And there are professional organizations, like the nonprofit California Maternal Quality Care Collaborative (CMQCC), that provide hospitals with guidance on evidence-based strategies and practices that can lower C-section rates—by providing data to doctors as well as to the public, for example.
Making a hospital’s C-section rate public not only helps families choose a hospital, but can also motivate hospitals and doctors to change their practices. “There’s a lot of denial of the problem of high C-section rates, and we need to overcome it,” says Main, who notes that simply having the data is an important first step in correcting the problem. In fact, three hospitals that were part of a pilot project with CMQCC in 2016 were able to successfully reduce their C-section rates.
And Caughey notes that hospitals should track not just C-section rates, but the number of newborns who have complications or die in their facilities.
Similar examples of improvement include Carolinas HealthCare System, in Charlotte, NC, which used a data-driven approach and safely lowered their C-section rate for low-risk deliveries from 27 percent to 21.8 percent over a two-year period. Beth Israel Deaconess Medical Center, in Boston, MA, reduced its C-section rate from 34.8 percent to 21.2 percent over eight years, using several evidence-based strategies, including sharing data with providers on their C-section rates. And this reduction occurred without increasing complications in babies or mothers.
In the meantime, while hospitals around the country are working to lower their rates of unnecessary C-sections, women can arm themselves with CR’s detailed data about C-section rates at their local hospitals so they can make an informed decision about where to give birth, says Peter.
For more on what you can do to avoid an unnecessary C-section, see our article “How to Cut Your Odds of Having a C-Section.”
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