By Doris Peter, Ph.D, Director, Consumer Reports Health Ratings Center and Tara Haelle, Freelance Health and Science Journalist
Just in time for Cesarean Awareness Month, Consumer Reports is releasing an investigation into C-section rates of more than 1,200 hospitals across the country. And the results are sobering.
Six in 10 hospitals had C-section rates for low-risk deliveries among first-time mothers that were above the national target for low-risk deliveries, which isof 23.9 percent. Consumer Reports' investigation also found wide variation in C-section rates among individual hospitals -- ranging from a low of 9 percent to a high of 68 percent -- among individual hospitals for these NTSV (nulliparous, term singleton, vertex, or NTSV) deliveries. These data are limited to C-sections for - which limited the data collection to first-time mothers giving birth 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 births 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 C-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 births at Riverside Community Hospital.
This suggests that where a woman delivers her baby could be one of the biggest risk factors for a C-section, 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 C-section 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. where births take place.
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 C-section rates may depend more on the culture of a hospital than on medical reasons. Although culture is hard to measure, and hard to 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 parents, armed with this information, hold hospitals accountable by choosing to take their business elsewhere. That's where childbirth education can help. In a childbirth class, parents can learn about the local hospitals' cesarean rates, and feel empowered 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 increase the likelihood that their birthing preferences are respected.
Of course, some hospitals don't report their C-section rates. In this situation, parents can talk to their childbirth educator to figure out who to call at local facilities to find out C-section rates, and 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 parents ask the right questions and understand the answers received.
Childbirth education can play an important role in helping pregnant families 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.
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