Hospitals across California are performing cesareans at strikingly different rates. It seems a lot depends on which hospital a mother heads to and what doctor delivers her baby. Guest: Nate Johnson, reporter with California Watch, a project of the Center for Investigative Reporting.
For-profit hospitals performing more C-sections
For-profit hospitals across the state are performing cesarean sections at higher rates than nonprofit hospitals, a California Watch analysis has found.
A database compiled from state birthing records revealed that, all factors considered, women are at least 17 percent more likely to have a cesarean section at a for-profit hospital than at one that operates as a non-profit. A surgical birth can bring in twice the revenue of a vaginal delivery.
In addition, some hospitals appear to be performing more C-sections for non-medical reasons — including an individual doctor’s level of patience and the staffing schedules in maternity wards, according to interviews with health professionals.
Across the state, more women are having C-sections for a variety of reasons: a rise in obesity and the number of older mothers, fear of lawsuits among doctors and hospitals, and a growing cultural acceptance of the procedure. Rather than examine these well-known trends, California Watch looked at why individual hospitals are performing cesarean sections at higher rates than others.
The statewide database revealed significant differences among 253 hospitals in California. Women, whose pregnancies were deemed to be low-risk, had a 9 percent chance of giving birth by C-section at the nonprofit Kaiser Permanente Redwood City Medical Center, for example, while at the for-profit Los Angeles Community Hospital, women had a 47 percent chance of undergoing a surgical birth. When you factor in moms who needed to have C-sections for medical reasons, the Los Angeles hospital?????s rate jumps to 59 percent. In Riverside County, hospitals just miles apart had dramatically different rates, even though they serve essentially the same population.
Some critics say the numbers provide ammunition to those who have long suspected that unnecessary C-sections are performed to help pad the bottom line.
“This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate," said Desirre Andrews, president of the International Cesarean Awareness Network, a nonprofit group that would like to see C-sections only in cases of medical need.
To doctors and other health professionals, the results of the analysis were troubling.
“We take this extremely seriously. The wide variation in C-section rates really is a cause for concern,” said Dr. Jeanne Conry, California district chairwoman of the American Congress of Obstetricians and Gynecologists.
This was the first independent analysis of C-section rates at the 253 hospitals reporting birth statistics to state health authorities from 2005 through 2007 and the first showing for-profit hospitals with higher rates than nonprofit ones. Studies in other countries have shown the same relationship between for-profit health care institutions and C-sections.
The notion that hospitals could be pushing C-sections for money is “a wrong premise,” according to Tenet Healthcare representative Rick Black, who said the decision to perform the surgery is made by the doctor and patient, while the hospital exerts no direct influence.
“You don’t just come into a hospital and they say, ‘We want to give you a C-section so we can drive up profits.’ ”
In 2008, more than 180,000 C-sections were performed in California. It’s unclear what percentage of these procedures led to adverse outcomes because some injuries are the result of underlying conditions.
By comparing hospitals with similar demographics, the California Watch analysis revealed that rising C-section rates cannot be completely attributed to changes in patient health and preference.
“If you look at this variation among hospitals, it’s clear we can’t just blame women,” said Debra Bingham, president-elect of Lamaze International, a group that promotes natural birth.
Pressure for procedure
Even at nonprofit hospitals, some women say they felt pressured to have a C-section.
Rebecca Zavala, 29, a teacher and makeup artist in Ventura, was one.
Zavala consented to have her delivery induced a week early because the baby’s head seemed large and because the doctor was about to leave for vacation.
Zavala went to the nonprofit Santa Monica-UCLA Medical Center, where nurses gave her drugs to dilate her cervix and start the contractions. After four hours, in which labor progressed slowly, Zavala’s doctor broke her water and turned up the drug, stimulating contractions.
Shortly thereafter, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed. Nurses congratulated Zavala on being an accommodating patient.
But Zavala said she felt manipulated. Her doctor hadn’t told her that induction increased the likelihood that she’d have a C-section, and that C-sections came with health risks, she said. Now that she is pregnant again, she has learned that most hospitals are unlikely to allow a woman with a prior C-section to give birth naturally.
“She told me nothing,” Zavala said of her doctor, noting that the doctor left for her vacation shortly after the delivery.
The hospital could not discuss the specifics of the case due to patient privacy, but responded with the following statement:
“Many factors go into the decision to perform a C-section delivery, with mother and baby safety foremost among them. Our policy requires physicians to obtain informed consent from patients undergoing C-sections. The process, which we followed completely, involves discussing the risks, benefits and alternatives to the procedure, and documenting that the discussion occurred and the patient opted to proceed.”
Zavala’s doctor did not wish to comment for attribution. Zavala did sign the consent but said it was impossible for her to interpret and assess the issues laid out in small print. Santa Monica-UCLA Medical Center has one of the highest rates of C-section deliveries in the state, ranking 15th out of 253 hospitals, for women whose pregnancies were deemed to be low-risk.
For some, a C-section can have devastating consequences.
After Heather Kirwan had been in labor for a few hours her doctor at Rancho Springs Medical Center in Murrieta urged her to have a C-section, warning that the baby was too big for her birth canal. She reluctantly agreed to the procedure, but now questions that decision.
“She ended up being a 5-pound, 12-ounce baby,” said Kirwan, 26, a manager for The Home Depot who lives in Murrieta. “So that was obviously a lie.”
A year and a half later, Kirwan was pregnant again, but the doctors found that the embryo was developing outside the uterus. Before her C-section, Kirwan said no one had warned her that C-sections increase the risk of this life-threatening condition, called ectopic pregnancy. And if it were listed in her lengthy consent form at the time of her first delivery, Kirwan said, no one bothered to point it out.
The doctors removed the embryo, along with one of Kirwan’s ovaries and fallopian tubes. She has been unable to conceive since.
“I’ve been trying for years and years, and I still can’t get pregnant. It’s very heartbreaking,” Kirwan said. “I just want people to know the risks.”
In a recently published study, the Centers for Disease Control and Prevention showed that a 27 percent increase in severe maternal injuries in the United States between 1998 and 2005 was associated with higher rates of cesarean sections.
Kirwan’s doctor and Rancho Springs Medical Center didn’t respond to requests for comment. The hospital’s C-section rate is among the state’s lowest, ranking 207th out of 253 medical centers.
Searching for a link
Medical experts have been unable to pinpoint exactly why some hospitals perform far more C-sections, or “operative deliveries,” than other medical facilities.
Yet, one important factor has always loomed over the debate about the rise in C-sections: the bottom line. In California, hospitals can increase their revenue by 82 percent on average by performing a C-section instead of a vaginal birth, according to a 2007 analysis by the Pacific Business Group on Health.
The group – a coalition of business, education and government agencies – estimated that average hospital profits on an uncomplicated C-section were $2,240, while profits for a comparable vaginal birth were $1,230.
California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus – positioned head down – at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, while for-profit hospitals had a rate of 19 percent.
That may seem like a small percentage gap to the casual observer, but medical experts consider it a significant difference. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital.
“That’s a decent-sized difference,” said Gene Declercq, professor of community health sciences at the Boston University School of Public Health.
Less than one in five maternity hospitals in the state is a for-profit institution, but among the 15 hospitals with the highest rates of C-sections, 10 are for-profit facilities. Among the 15 hospitals with the lowest rates, none are for-profit medical centers.
Riverside County Regional Medical Center in Moreno Valley has one of the lowest C-section rates at 9 percent.
Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional, attributes his hospital’s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.
“If I come in in the morning, look over the charts and see that one of the patients just had a C-section without medical indication,” Valenzuela said, “you can bet that I’m going to start asking questions.”
A few obstetricians, like Dr. Jeffrey Phelan, director of quality assurance for obstetrics at Citrus Valley Medical Center in West Covina believe that a higher C-section rate might be beneficial, especially in preventing infant brain injuries. In rare cases, when a baby’s oxygen supply is cut off during birth, the baby may suffer brain damage. Because C-sections allow greater obstetrical control, Phelan says this problem might be alleviated by eliminating vaginal birth altogether.
However, most researchers agree that the rising number of birthing surgeries has done nothing to improve the health of mothers or babies, while exposing them to side effects. The accumulation of this data led The Joint Commission, the nation’s top hospital accreditation organization, to announce this year that it would begin using low-risk C-section rates to measure hospital quality.
Dr. David Lagrew, medical director of Saddleback Women’s Hospital in Orange County, spends about half his time delivering babies and says the change is welcome.
“The big problem, of course, is that cesarean section has a number of downsides, such as increasing the maternal death rate, infections, blood loss, a lot of complications long term that we are just now beginning to understand,” he said.
“The great debate is what should the C-section rate really be?” Lagrew added. “With things getting more complicated, as far as obesity and older women, it shouldn’t be 10 percent probably – but it shouldn’t be 50 percent, either. You want to find the sweet spot.”