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. 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.
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.
The analysis challenges some common assumptions about C-sections, including that wealthier women are more likely to opt for a surgical birth. Higher C-section rates were found at hospitals catering to all ethnic groups and economic classes. And there was no correlation between C-section rates and the percentage of a hospital’s business from low-income or indigent patients receiving Medi-Cal, the state’s Medicaid program.
But of the five hospitals in California with the highest C-section rates, four were for-profit hospitals in poorer parts of Los Angeles County, where the African-American and Hispanic populations are above the state average. Hospitals in Southern California tended to have higher rates than in the north, which may suggest a cultural influence.
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.
But some hospital officials dispute the notion that their institutions could be pushing C-sections for money. It 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.’ “
Gene Declercq, professor of community health sciences at the Boston University School of Public Health, agrees that hospitals would not explicitly push C-sections for profit. But subtle incentives to increase efficiency could have the same effect.
“There are factors that are attractive to hospitals in terms of training and staff and facilities,” he said. “It’s a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need.” Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.
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.
California Watch previously reported that the state’s maternal death rate has increased dramatically, and researchers are exploring the possible connection to the rise in C-sections during the same time period. Other media outlets, including ABC’s “World News” and the Los Angeles Times, followed up with reports about this trend. 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.
This finding adds to a growing body of studies that explain the rise in C-sections, said Carol Sakala, director of programs at Childbirth Connection, a maternity care advocacy group.
“Much variation in cesarean rates is due to differences in practice style and is unrelated to needs and preferences of childbearing women,” Sakala said. “The likelihood that a woman will have a cesarean with all the short- and longer-term excess risks of surgery to her and her newborn, and excess expense is greatly influenced by the hospital she enters to give birth and the caregiver attending her 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.
“It felt like there was this monster on top of me all of a sudden,” Zavala said. “It was terrifying. I was totally unprepared for anything like that.”
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 are 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.
In June, a group of scientists writing in Obstetrics & Gynecology, the journal of the American College of Obstetrics and Gynecology, found clear evidence of “substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences.”
Another analysis of C-section rates noted that the variation among hospitals seems to defy a rational pattern. That 2007 study, in the American Journal of Obstetrics & Gynecology, concluded that the “rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making.”
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. (When calculated without weighting averages by number of patients, the difference is slightly larger.)
“That’s a decent–sized difference,” said Boston University’s Declercq.
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.
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.
Clinical practices and local leaders
Citrus Valley Medical Center’s 29.3 percent low-risk C-section rate is the highest of any nonprofit maternity hospital in California. The reason for these C-sections is often listed as “failure to progress,” but the nurses have another name for it: “failure to wait.”
This is particularly a problem at Citrus Valley, where nurses have been written up for insubordination after asking doctors to give their patients more time or complaining to administrators about doctors rushing to perform C-sections, according to Nancy Carder, nursing practice representative for the California Nurses Association.
But Phelan said there is no drive for speed at Citrus Valley, only a drive for safety.
“I’ll put our perinatal safety record up against anyone in the state, and in the nation, for that matter,” he said. “We’ve seen continued improvement over the years. Whether higher C-section rates are a part of that, I don’t know.”
Phelan acknowledges that he may be part of the reason there are so many C-sections at Citrus Valley. A lawyer as well as a doctor, he has written about obstetric liability, and testified in malpractice cases. He acknowledges that his advice about avoiding lawsuits “has an impact.”
All hospitals operate under the same malpractice rules in California, but they react to the threat of lawsuits differently. “In published studies and case reports, the biggest reason for the variations has been shown to be clinical practices and local leaders,” said Bingham, of Lamaze International.
The ultimate cause of the high C-section rate, Phelan contends, is patient choice.
“I think, to a large extent, consumers want to have elective cesarean deliveries,” he said.
But Citrus Valley labor and delivery nurses said it doesn’t make sense that more patients would prefer C-sections at their hospital compared with others nearby. According to several nurses, it’s often the doctors, not the patients, who make the choice.
The reason people often don’t know the risks associated with C-sections is that they crop up years later, said Aaron Caughey, chairman of the Department of Obstetrics & Gynecology at Oregon Health & Science University.
The first C-section is very safe for the mother and it’s unclear if it lowers the risk to the baby, but it may also cause a small increase in the risk of future stillbirths, while increasing the risk of maternal injury in subsequent pregnancies, he said.
Caughey’s research predicts that if the C-section rate continues to increase at its current rate, it will cause 1,620 more hysterectomies and 50 more maternal deaths each year in the United States by 2020.
“When there is a bad outcome on the third pregnancy, people don’t think, ‘Oh, it was the first C-section eight years ago,’ ” he said. “We kind of forget to look back.”
Divide in the Inland Empire
The problem exposed by the variation in C-section rates is clearly illustrated by two nonprofit hospitals in the Inland Empire.
Riverside County Regional Medical Center in Moreno Valley is on the eastern rim of the Los Angeles Basin, where the coastal smog piles up against the desert mountains. Hemet Valley Medical Center, just 22 miles away, sits at the base of the same mountains, in the same haze.
And yet, between 2005 and 2007, Hemet Valley had one of the highest C-section rates in the state, 28.7 percent for low-risk pregnancies, while Riverside County Regional had one of the lowest at 9 percent.
Riverside County Regional abuts a subdivision for doublewide trailers. Hemet Valley is on a bedraggled commercial strip. In Hemet Valley’s medical service area, 15.5 percent of the people live below the poverty level. For Riverside County Regional, that number is 15.4 percent. The ethnic makeup of the two areas is similar. Doctors at both hospitals practice under the same malpractice laws.
So why are women more likely to undergo a C-section in Hemet Valley? For Jerri Randrup, vice president for communications and marketing at Hemet Valley, the difference is a mystery. The hospital had to enter bankruptcy a few years ago, but that hasn’t affected the quality of care, she said.
“I can’t tell you what we were doing in the past,” said Randrup, noting that the hospital’s rate had fallen in 2009. “But what I can tell you is there is a team in place that is very focused on quality care and patients, following standards and getting our nurses trained.”
There’s no mystery for Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional, who is on call about twice a month to deliver babies. “These things don’t happen by accident,” he said.
Valenzuela 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.
By contrast, most doctors, who must be there when the baby arrives to make their fee, face a dilemma unknown to shift workers: either wait hours for a vaginal delivery or perform a C-section.
“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.”
Other hospitals rely on a similar system. Kaiser Permanente hospitals use this shift-work model and generally have lower C-section rates. Dr. Tracy Flanagan, who regularly delivers babies and is director of women’s health at Kaiser Permanente Northern California, has worked under both systems and understands how the forces of time can affect a physician in private practice.
“You are sitting in labor and delivery for 12 hours and she’s barely making progress, and your family is yelling at you wondering when you are going to come home,” Flanagan said. “There’s tremendous pressure. In addition, you know that you will get paid the same or more for doing a C-section. Our medical system makes it hard to do the right thing. That’s a big reason I moved over to Kaiser.”
Kaiser also addresses this issue by hiring midwives, who are able to conduct births more cheaply than doctors. Midwives participate in the majority of Kaiser births.
Last spring, The Joint Commission, the principal body that evaluates hospitals in the United States, instituted a standard designed to prevent frivolous C-sections. The Joint Commission wrote that hospitals with low C-section rates “have infant outcomes that are just as good, and better maternal outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses, are the major driver for the difference in rates within a hospital.”
This pressure from an organization with the power to remove a hospital’s accreditation should make a difference, said Lagrew, of Saddleback Women’s Hospital. More hospitals are working to reduce C-sections by limiting medical interventions like induction of labor and hiring shift-work doctors or midwives who can afford to be more patient with long labors.
Though some hospitals have yet to respond, the pendulum is starting to swing back, Lagrew said.
“The great debate is what should the C-section rate really be?” he said. “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.”
