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Still too many C-sections at California hospitals

Phoebe ! via Flickr Creative Commons

For some pregnant women, giving birth by Cesarean section is critical, even life saving. But at far too many hospitals in California and across the nation, lots of women are having C-sections when the procedure is not medically indicated, according to newly released data.

The Leapfrog Group is trying to measure how often women are having these unnecessary C-sections. Last week, it released statewide and hospital-level statistics detailing how often first-time moms with lower-risk pregnancies – defined as those that have reached the 37th week or later and consist of one fetus in the head-down position – give birth via C-section.

The group's findings come at a time when experts are cautiously optimistic that the country's C-section rate might be on the decline. Nationwide, the C-section rate among first-time moms with low-risk pregnancies jumped by 44 percent over a decade, from 19.5 percent in 1999 to 28.1 percent in 2009. Since then, it's been slowly dropping, hitting 26.9 percent in 2013.

Why do we care about C-section rates?

In some situations, C-sections can be life saving for moms and babies. But the procedure is major surgery, so experts say it should be performed only when indicated.

This is especially important for a woman's first birth. During any pregnancy, a woman undergoing a C-section is at risk of complications like bleeding, infection, blood clots and injury to other organs, says Dr. Aaron Caughey, chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University.

"If we're doing an indicated C-section, it means that we think the risks are great enough to her or the baby right now to outweigh all future considerations," Caughey says.

But once women have one C-section, they're very likely to have another. And there are more health risks during subsequent C-sections: The placenta could implant in the C-section scar, resulting in the mom suffering a life-threatening hemorrhage, Caughey says. The baby could also be delivered pre-term.

How high are the rates, anyway?

The federal government's goal is to reduce the C-section rate for these low-risk pregnancies to 23.9 percent by 2020. California still has a ways to go, according to the Leapfrog analysis: It finds that the average C-section rate for first-time, low-risk pregnancies here was 25.7 percent in 2014.

Here in Southern California, some hospitals have already surpassed that target. At Pomona Valley Hospital Medical Center, for example, the C-section rate for first-time moms with low-risk pregnancies was 18.9 percent in 2014.

Other hospitals, though, are far from the target rate. At Foothill Presbyterian Hospital in Glendora, for example, the C-section rate among lower-risk pregnancies is 38.9 percent; it's 38 percent at White Memorial Medical Center in Los Angeles, according to Leapfrog.

One shortcoming of Leapfrog's data, though, is that 139 of the state's 297 hospitals - or more than 45 percent of hospitals - declined to respond to the survey. Leah Binder, president and CEO of Leapfrog, says hospitals that don't report their C-section rates are doing a disservice to health consumers, who want to make informed decisions.

"What's most important about our data is not the data itself," Binder says. "What's most important about our data is how people can use it. We really want women and families who are facing a pregnancy to have something they can use to make the best possible decisions about where they seek care."

Slightly older data from another source, the California Hospital Assessment and Reporting Task Force, shows some Southern California hospitals that didn't respond to Leapfrog's survey had very high C-section rates in 2013.

East Los Angeles Doctors Hospital, for example, declined to respond to Leapfrog’s survey. But according to the task force, the hospital's low-risk C-section rate was 59.8 percent in 2013. Los Angeles Community Hospital also declined to respond to Leapfrog's survey, but the task force's data show its low-risk C-section rate was 68.8 percent in 2013.

The state's hospital assessment task force will have 2014 data available next month, according to a spokesman.

I reached out to Foothill Presbyterian, White Memorial, East Los Angeles Doctors Hospital and Los Angeles Community Hospital. White Memorial is the only facility that responded. In a brief statement, spokeswoman Alicia Gonzalez said the hospital is working on improving its C-section rates.

Why are some rates so high?

Here's one explanation: Caughey says overall C-section rates started climbing in the late 1990s, as the country's obesity epidemic was escalating.

That meant more obese women - and more women with chronic health conditions, like diabetes, hypertension and kidney disease - were getting pregnant. It led to more high-risk pregnancies, he says.

Caughey says it would make sense for the C-section rate to increase in proportion to the rate of high-risk pregnancies. The problem, he says, is "we don’t really think the C-section rate went up appropriately. We think it went up faster than the changes to the population."

Dr. Elliott Main, director of the California Maternal Quality Care Collaborative, offers another reason: During that time period, he says, key opinion leaders – including insurance company leaders, hospital directors and department chairs - simply stopped caring about the C-section rate.

"And if no one cares, there's no pressure to keep it down, and it just floated up like a balloon," Main says.

Without that pressure, he says, many doctors resorted to C-sections when a woman's labor slowed. In these cases, he says, C-sections were a result of "a lack of patience."

"That's the variable part between hospital and hospital, and even doctor and doctor in the same hospital," Main says. "And that's actually something we can re-educate the nursing and physician staff about."

Turning the tide

Lowering C-section rates could require a cultural shift among providers and patients.

Pomona Valley Hospital Medical Center took on that challenge a few years ago. Several years ago, too many women were having multiple C-sections and suffering serious complications,  says M. Hellen Rodriguez, the hospital's director of maternal and fetal medicine.

So the hospital took action: Rodriguez says it internally published staff doctors' C-section rates so they could see how they compared with their peers. That spurred competition among physicians to lower their rates. Pomona Valley carried out significant education efforts with providers, so they would know when C-sections were truly medically indicated, says Rodriguez. It also encouraged its doctors and nurses to improve their communication and work together as a team to support pregnant moms.

Pomona Valley's approach is working, although Rodriguez says she isn't focused too closely on the numbers: "Our goal is to make sure that every Cesarean section that is done is medically indicated."