By Doris Peter, Ph.D, Director, Consumer Reports Health Ratings Center and Tara Haelle, Freelance Health and Science Journalist

April is Cesarean Awareness Month and everyone is in agreement that the cesarean rate in the USA is much too high as it hovers around 32.2%. Other developed countries also struggle with too many babies born surgically. In resouce poor locations around the world, parents and babies die due to the lack of safe cesarean options. Neither situation is good for maternal or infant health. Consumer Reports, an invaluable consumer magazine and accompanying website is taking the lead on helping consumers be able to access cesarean rates in the USA on an individual hospital level. Armed with this information, expecting families can make infomed choices about facilities and providers. Dr. Doris Peter, the Director of the Consumer Reports Health Ratings Center and Health and Science writer Tara Haelle help birth professionals to know what information is available to share with consumers and why these ratings are important for people to know. Are the hospitals in your area listed? Do you share resources such as this with your clients and students? How do you do that effectively?- Sharon Muza, Community Manager, Science & Sensibility

Just in time for Cesarean Awareness month, Consumer Reports is releasing an investigation into cesarean section rates of more than 1,200 hospitals across the country. And the results are sobering.

Six in ten hospitals had C-section rates above the national target for low-risk deliveries of 23.9 percent. Consumer Reports' investigation also found wide variation in C-section rates among individual hospitals for these NTSV deliveries-which limited the data collection to first-time mothers delivering full-term singleton babies who were in the vertex (head down) position for birth-ranging from a low of 9 percent to a high of 68 percent.

Among larger hospitals (those with at least 3,500 total deliveries in 2014 or 1,000 low-risk births in the 12-month period that ended in June 2015), Crouse Hospital in Syracuse, N.Y. had the lowest cesarean section rate for these low-risk deliveries, at 11 percent; South Miami Hospital had the highest rate, at 53 percent.

The analysis found worrisome variation even among hospitals in the same communities. For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were. In southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at nearby Riverside Community Hospital.

This suggests that where a woman delivers her baby could be one of the biggest risk factors for whether she has a cesarean section or delivers vaginally, says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.

Unfortunately, it has been difficult for families to get reliable information about the C-section rates at the hospitals in their communities. Consumer Reports' new Ratings are an important step in correcting that problem, providing the most comprehensive information available on Cesarean delivery rates at the individual hospital level.

Yet even this information is incomplete. That's because we must gather that information from a variety of sources, including hospitals themselves, state governments, and nonprofit organizations, notably the Leapfrog Group and, in California, the California Maternal Quality Care Collaborative (CMQCC).

In most cases, reporting the information is voluntary. As a result, our Ratings include C-section rates for only about 40 percent of the estimated 3,000 hospitals in the U.S. that deliver babies.

Consumer Reports hopes that our Ratings will not only help consumers make informed decisions when choosing a hospital and motivate hospitals to improve, but also encourage all hospitals to report their C-section data. Among the many hospitals that don't report are 24 hospitals with more than 5,000 births, including Magee-Womens Hospital of UPMC in Pittsburgh, the Memorial Hermann Northwest Hospital in Houston, and New York-Presbyterian Hospital in New York City.

Pregnant people and their families have a right to this information, especially because high Cesarean section rates may depend more on the culture of a hospital than on medical reasons. Although culture is hard to measure and change, it's not impossible. In fact, it's already happening. "Over the past three or four years, we're seeing a leveling off and a slow reversal because we're talking about it and trying to change the culture back a little bit," 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 new ACOG/SMFM guidelines for safely reducing C-section rates.

At some hospitals we spoke with, such as Sharp Mary Birch Hospital for Women & Newborns in San Diego, one of the strongest motivators was simply publishing doctors' C-section rates within the hospital. When doctors saw how they rated compared to their peers, many of their numbers started to drop, says Colleen McNally, M.D., chief medical officer of the hospital. "I think transparency will help us lower that rate even more," McNally says. "Nobody wants to be an outlier."

A similar strategy worked at Hoag Hospital in Newport Beach, Calif., says Elliott Main, M.D., medical director of the CMQCC. He explains that how doctors are trained and who they work with influences their C-section rates. "Peers are a big driver," Main said. "Changing the culture of the unit to be more supportive of vaginal delivery and sharing individual practitioner rates were both critical for bringing down the C-section rate. Many doctors did not know their own rates and when they saw other physicians with much lower rates it made a strong impact," he says.

Ultimately, real and lasting change in reducing high C-section rates may come about only when consumers, armed with this information, hold hospitals accountable by choosing to take their business elsewhere. That's where childbirth educators can help. By using class time to show these Ratings to pregnant clients and then explaining what these Ratings may reveal about a hospital, childbirth educators can help empower pregnant people to become more informed about the facilities where they may give birth. For those with the option of choosing a facility, this knowledge can be particularly powerful in helping people increase the likelihood that their birthing preferences are respected.

Of course, some hospitals don't report their C-section rates. In this situation, childbirth educators can use this as an opportunity to help families figure out who to call at local facilities to find out C-section rates. They can discuss how to initiate a conversation with their prenatal provider about their own C-section rates. For pregnant people using a doula, the doula may be able to help clients to ask the right questions and understand the answers they receive.

The most important practical take-home, then, is that childbirth educators can play an important role in helping pregnant clients determine which hospital or birthing facility may best suit their needs, how to communicate their preferences to their providers, and how to do whatever is possible to increase the likelihood those preferences are respected.

About Doris Peter, PhD and Tara Haelle

Doris Peter, PhD is the Director of the Consumer Reports Health Ratings Center, part of the nonprofit organization, Consumer Reports. She leads multidisciplinary teams that develop consumer-friendly translations and presentations of data to help consumers understand comparisons of the quality and value of health care products (e.g., drugs) and services (e.g., hospitals, physicians). These communications reach millions of consumers through Consumer Reports' media channels, and through those of Consumer Reports' partners.

Tara Haelle is a health and science journalist whose work has appeared in NPR, Scientific American, Wired, Parents, Medscape and Slate. She is a regular contributor at Forbes and writes the parenting blog Red Wine & Applesauce. She is coauthor of The Informed Parent: A Science-Based Resource for Your Child's First Four Years and of several children's science books. Follow her at @tarahaelle.

photo credit for Tara Haelle headshot is Jim Coventry

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