A woman who’s pregnant with her first child often doesn’t choose a specific hospital for her baby’s birth.
Instead, she goes to the one where her trusted doctor practices.
That seemingly simple decision may have serious consequences.
The pregnant woman may end up being rushed into the operating room during labor.
Most low-risk mothers who are pregnant with their first child aren’t sure how long their labor will last, but most are not prepared for a cesarean birth, or C-section.
The U.S. Department of Health and Human Services’ (HHS) Healthy People goal for C-sections on first-time, low-risk mothers is less than 24 percent nationwide by 2020.
Data from hospitals across the United States, however, show that 56 percent of hospitals perform C-sections at much higher rates.
In California, where 1 in 8 babies in the U.S. are born, C-section rates for low-risk mothers vary from 12 percent to 70 percent, depending on the hospital.
A woman’s chance of having a C-section is determined largely by the hospital where she delivers her baby.
“Whenever you see a huge variation like this among low-risk, first-birth mothers, it sets off an alarm bell,” noted Stephanie Teleki, MPH, PhD, the director of evaluation and impact at the California Health Care Foundation (CHCF).
Now, women having a baby in California can turn to Yelp to help them make better decisions about where they give birth.
State and nonprofit organizations like CHCF and Cal Hospital Compare partnered with Yelp to display information that’s critical for making an informed decision about delivery.
CHCF, through this Yelp initiative and other approaches, would like to shrink the variation in C-section rates and see every single California hospital’s average for C-sections on low-risk mothers below 24 percent.
Teleki notes that the goal is already generous since the World Health Organization (WHO) believes the ideal C-section rate is 10 percent to 15 percent.
“No one knows what the exact perfect number is, but it’s not 70 percent and it’s not 50 percent,” Teleki told Healthline.
She also stressed that the goal applies to non-medically necessary surgeries.
“No one is saying the C-section rate should be zero. These are very important, life-saving procedures when used correctly,” she said. “What we’re saying is that C-sections have become overused and we could be doing more harm than good.”
A risky alternative to natural birth
Over the past decade, the C-section birth rate has risen by 50 percent in the United States.
Approximately one-third of babies are born via surgery.
“Cesarean section, by its nature, is a major surgical procedure,” said Dr. Abraham Lichtmacher, chief of women’s services at Lovelace Health System in New Mexico.
The immediate risks of a C-section are excessive bleeding or hemorrhage. These complications require blood transfusions and can lead to significant infections, according to Lichtmacher.
There’s also a chance that organs close to where doctors are operating are damaged.
“There are also more extended risks, including delayed recovery. Typically, patients that have a vaginal birth go home after one or two days, while those with cesarean birth go home after three to four days,” Lichtmacher explained.
Women who have C-sections also take about twice as long as women who have vaginal, or natural births, to recover after they leave the hospital.
Lichtmacher told Healthline that a main concern is what happens with the next pregnancy.
Once a woman has a C-section, she’s 90 percent likely to have C-sections on all future births. The vaginal birth after cesarean (VBAC) rate, also listed on Yelp as part of this new initiative, speaks to this likelihood.
“Every subsequent surgical procedure increases the risk of complications for that patient. What if a patient wants to have four or five children? Will we compromise that or make it more difficult for her with that first cesarean birth?” Lichtmacher asked.
Why are some hospitals C-section happy?
You may know someone who scheduled a C-section ahead of her due date. But the American College of Obstetricians and Gynecologists (ACOG) estimates that only 2.5 percent of women ask for a C-section, indicating that elective surgeries aren’t a primary driver of the high C-section rate.
“There’s been a lost art of labor management, so over time we’ve gone toward using monitors and surgical interventions to deliver babies,” Teleki explained.
The two main drivers of high C-section rates are cost and time, according to both Teleki and Lichtmacher.
The costs for a cesarean birth are significantly higher than for natural births.
Women who have C-sections have major surgery, stay in the hospital longer, and require more monitoring.
So, when a hospital performs such an operation, they’re reimbursed at a higher rate by an insurance company than for a natural birth.
Supporting natural births can also cost a hospital more, since they still need to have the resources to respond quickly when emergency situations occur. This includes having an anesthesiologist and surgeon on duty, Lichtmacher pointed out.
“Some facilities cannot or do not want to be able to provide those resources,” he said.
However, natural births usually take more time overall than a cesarean birth.
Both Teleki and Lichtmacher noted that many OBs also have a clinical practice, so they’re juggling their practice and the women whose babies they’re trying to deliver.
“It helps to have certainty when you’re trying to manage your time. C-sections are more predictable,” Teleki stated.
There are also other factors that contribute to the overuse of C-sections for low-risk mothers, including worry on the part of the OB that not calling for surgery soon enough is a liability.
“OBs are some of the most heavily sued providers,” Teleki said.
So, they often choose to not go out of their way to support a natural birth, since it could put them at more legal risk.
The multi-pronged solution
There are many things driving the increase and overuse of C-sections, so “there’s not going to be a silver bullet to fix the problem,” Teleki said.
CHCF is working with insurance companies and groups like Smart Care California to align payments with desired outcomes.
With a so-called blended payment, hospitals will be reimbursed the same amount for vaginal births and C-sections, erasing the cost incentive.
In 2019, Covered California, the state’s insurance exchange, will start excluding insurance plans that contract with hospitals that don’t hit the sub-24 percent standard for low-risk C-sections.
“Payers are starting to say ‘Why are we paying for a hospital that has 70 percent cesarean birth rate?’” Lichtmacher said.
He also shared how Lovelace Health System, which has the fourth-lowest C-section rate in the country (13 percent) for large hospitals, has dis-incentivized C-sections.
First, Lovelace assigns the physician covering the delivery and labor unit for a full day.
“If I’m a physician and I’m going to be there for 24 hours, there’s no incentive to want to deliver a patient to go home or to deal with my patient in a clinic because I have to split my time. Time pressures are eliminated,” Lichtmacher explained.
Lovelace also doesn’t pay doctors per birth, so they reduce financial incentives to deliver babies quickly.
Third, Lovelace has a large midwifery component to their hospital delivery system. Statistically, hospitals that have midwifery services tend to have lower cesarean birth rates, according to Lichtmacher.
“Midwives are trained in the art and patience of births,” Teleki agreed.
Why Yelp is a valuable partner
“We all know someone who’s gotten a C-section and it’s been just fine. It’s getting lost in our culture that this is major abdominal surgery,” Teleki said.
“Consumers are an important part of the discussion and the solution,” she said.
With the Yelp partnership, “CHCF is trying to educate women on the value of not having a C-section unless they really need one, and how important what hospital you go to is.”
“Even if you can’t change hospitals, it’s still helpful to know what kind of situation you’re walking into,” Teleki explained.
She said knowledge empowers women to have conversations with their care provider and try to plan for the type of birth they want.
“Commentary and storytelling, like on Yelp, is an important part of our culture. By putting the clinical quality measures on Yelp, we’re trying to give the data a chance to be considered alongside the comments,” Teleki stated.
Yelp will also be displaying the VBAC, breastfeeding, and episiotomy rates for all California hospitals to help women make more informed decisions about their baby’s birth.
The importance of available data
It’s not always easy to find out the C-section rate of a hospital.
Hospitals aren’t required to report that information to the public.
Consumer Reports collected publicly reported data on C-sections for hospitals nationwide and estimated that more than half of the approximately 3,000 hospitals that deliver babies in the U.S. haven’t shared their data publicly.
“A hospital’s C-section rate is an important consideration, and hospitals are beginning to report their data voluntarily. I’m an outlier in the sense that I think it should be public reported data. I think it should be mandatory,” Lichtmacher said.
According to Lichtmacher, many hospitals choose not to report their C-section data because they’re either too embarrassed by their rates or aren’t tracking outcomes closely enough to know what their rates are.
“Everyone needs to know what their rates are,” he said. “Until each hospital starts measuring what they do and then starts looking at it critically, we’re not going to be able to move the needle nationally on C-section rates.”
Describing the importance of bringing down the C-section rate for low-risk mothers, Lichtmacher explained, “Ultimately it’s best for the mother, it’s best for society, and it’s best for the baby.”