Six in 10 US hospitals rated by Consumer Reports have cesarean delivery rates above the national target of 23.9% for low-risk deliveries set by the US Department of Health and Human Services, and one in six have rates that are higher than 33.3%.
Overall cesarean delivery rates for low risk (nulliparous, term, singleton, vertex) pregnancies ranged from a low of 11% to a high of 53%, with wide variations among hospitals in the same community, as well as among similar institutions. The researchers also identified differences in cesarean delivery rates among geographic regions in the United States.
The findings from an investigation of more than 1200 US hospitals are described in an article published in Consumer Reports.
“Keeping the cesarean delivery rate low is a priority for some hospitals, and it’s less of a priority for others,” Dwight Rouse, MD, from the Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island, and professor, Department of Obstetrics and Gynecology, The Warren Alpert Medical School of Brown University, both in Providence, Rhode Island, toldMedscape Medical News. If no one is tracking it, making it a priority, presenting it monthly, and even talking to individual physicians, “the focus is elsewhere,” he said.
Dr Rouse was the senior author of a 2014 joint consensus document from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine on the safe prevention of the primary cesarean delivery.
Although the Joint Commission, an independent group that accredits healthcare organizations in the United States, has cesarean delivery rates for hospitals with more than 300 deliveries per year, they are not public. Therefore, for the current study, Consumer Reports used data from the Leapfrog Group, a national nonprofit organization that collects hospital performance data, for hospitals in every state except California. For California hospitals, the investigators used data from the California Maternal Quality Care Collaborative.
Rates Vary Markedly, Even Among Large Hospitals and in Same Communities
Of more than 1200 hospitals included in the ratings, almost 60% (743 hospitals) have cesarean delivery rates that are above the national target. Rates vary widely, even among large hospitals, defined as those with either a minimum of 3500 total deliveries in 2014 or 1000 low-risk deliveries during the 12-month period ending in June 2015.
The large hospitals with the highest rates include South Miami Hospital in Miami, Florida (53%); Hackensack University Medical Center in New Jersey (42%); Covenant Medical Center in Lubbock, Texas (42%); Woman’s Hospital of Texas in Houston (41%); and Palmetto General Hospital in Hialeah, Florida (38%).
The large hospitals with the lowest rates include Crouse Hospital in Syracuse, New York (11%); Yuma Regional Medical Center in Arizona (12%); Memorial Medical Center in Springfield, Illinois (12%); Utah Valley Regional Medical Center in Provo (13%); and Lovelace Women’s Hospital in Albuquerque, New Mexico (13%)
The report also notes that cesarean delivery rates vary even among hospitals in the same communities. For example, in Chicago, Illinois, the low-risk cesarean delivery rate is 30% at the University of Chicago Medical Center and 17% at Northwestern Memorial Hospital. Similarly, in southern California, the rate is 22% at Kaiser Permanente Riverside Medical Center and 35% at Riverside Community Hospital.
Differences in practice patterns may explain some of the variation, Dr Rouse said: “24/7 labor and delivery staffing…prevent[s] some of the C-sections that in the past have been done around 5:00 when the labor might be deemed too slowly progressive.”
He explained, “If there’s no pressure for the person who’s managing that labor to go home because they’re going to be in the hospital anyway, they may be more inclined to let that labor go on, and if you let labor go on, inevitably some women who were progressing slowly may very well deliver vaginally.”
Distinct Geographic Differences
Cesarean delivery rates are generally higher in the northeast and south, and lower in the west and Midwest. Higher rates are found in the District of Columbia (35%), Kentucky (32%), Florida (32%), and Mississippi (31%).
Cesarean delivery rates are lower in South Dakota (14%), Wyoming (17%), New Mexico (18%), and North Dakota (18%).
“The measure that Consumer Reports is using is decent, but it’s still fairly crude, and doesn’t quite account for interpatient differences that may be regional,” Dr Rouse said. “Women are heavier in the south, and obesity is associated with cesarean delivery and more protracted deliveries.”
“No Room for Error”
When it comes to delivering a healthy baby, “there’s no room for error,” Dr Rouse said. “Some physicians are more willing to tolerate degrees of abnormality of fetal heart rate tracing, and others aren’t.” Although there are risks associated with cesarean delivery, it is still “the safest major operation.”
“The proper comparison is not women who deliver vaginally, it’s women who attempt to deliver vaginally, because some of those women will be converted to a cesarean,” he added.
In addition, much of the current focus in obstetrics is on the management of postpartum hemorrhage, which is on the rise, as well as prevention of venous thromboembolism and complications of hypertension, and that is appropriate, Dr Rouse said. “There are only so many things you can focus on.”
What is not in the report may be as important as what is: Of an estimated 3000 hospitals with labor and delivery services, fewer than half report their cesarean delivery rates publicly, including 24 large hospitals with more than 5000 deliveries annually. These larger hospitals include New York City hospitals Mount Sinai Hospital, Mount Sinai St. Luke’s-Roosevelt, New York-Presbyterian Hospital, and New York University Langone Medical Center.
“You have to give credit to the hospitals that report their data, even the hospitals that are lower performers,” Leah Binder, chief executive officer of the Leapfrog Group, said in a Consumer Reportsnews release. “It’s the hospitals that don’t report that you have to wonder about.”
“Preventing the First Cesarean Is Key”
“Preventing the first cesarean is key, because more than 90% of women who undergo cesarean delivery in this country will have all of their subsequent births be by cesarean, so if you can prevent the first one, you may be preventing two or three downstream cesareans,” Dr Rouse said.
“Tolerating longer labors is clearly an important component of achieving higher rates of vaginal delivery…. A policy of nonintervention for labor that’s progressing, but progressing slower than expected [can help reduce cesarean delivery rates],” Dr Rouse explained. “In most cases, assuming the fetal status is reassuring, the thing to do is continue labor.”
If the fetus is breech at term, performing an external cephalic version may also help, because 2% to 3% of babies at term are breech, and “if you can turn half of those, some of those women will deliver vaginally,” Dr Rouse said.
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