W

omen with low-risk pregnancies who are trying to avoid caesarean sections often overlook the C-section rate of the hospital where they plan to give birth, new research shows.

The research, published in Thursday’s edition of the journal Birth and conducted by Dr. Neel Shah of Boston’s Beth Israel Deaconess Medical Center and five colleagues, showed that even among women with low-risk pregnancies who wish to avoid C-sections, 75 percent would stay with their chosen hospital, no matter how much higher its C-section rate.

Survey respondents said their months-long relationships with their obstetricians were more important than the hospitals where their doctors had privileges, and that they also felt that even if a hospital had a high C-section rate, their low-risk status and desire for a vaginal delivery made them believe C-sections wouldn’t apply to them. And even when told that their chances of having a C-section can depend more on administrative issues like staffing than their physical condition, women seeking vaginal deliveries held fast to their hospital choice.

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The problem: C-section rates vary wildly across US hospitals, with some as low as 7 percent and others as high as 70 percent. (Roughly 3 percent of women who have C-sections face complications, compared to 1 percent for vaginal deliveries.)

Shah, an OB-GYN who is director of the Delivery Decisions Initiative at Ariadne Labs, a research laboratory led by Dr. Atul Gawande, joined STAT by phone to discuss the findings. He pointed out that their survey pool was predominantly young women, under age 29, gathered on a particular discussion board, and more likely to be having their first child. This interview has been condensed and lightly edited for clarity.

Are the hospitals with the highest C-section rates simply pushing women into these procedures unnecessarily, or are there other factors at play?

Other factors are at play. About half of the C-sections performed in the US appear to be unnecessary. Part of what might be driving it are differences in how hospitals are managed. Take a doctor and put her in a different hospital, and her C-section rate may very well change. Something about the clinical environment seems to affect the way we make decisions. If we think there’s writing on the wall that suggests there’ll be a C-section, and all your beds are full or you’re running out of nurses, one way of speeding things along is to just do the C-section.

Is their obstetrician or midwife just not making it clear that they may not ultimately be there for the delivery, or that hospital-related factors can determine whether or not a C-section happens?

We found that most believe that the same person who has treated them during pregnancy will deliver their baby. That’s not true for many women, and they usually find that out over the course of the pregnancy. But my guess is that once you’ve picked your doctor, you’re not likely to switch if they’re at a hospital with a high C-section rate. There are a lot of ways consumerism breaks down in health care, and this is one of them.

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Based on your research, there’s a disconnect between women’s stated birth goals and how they manage those goals.

The biggest risk factor for this major abdominal surgery may not be her own medical risks or preferences, but literally which door she walks through. And women know that quality varies from place to place — they totally get that. Yet they often don’t pick their hospital on that basis. If they see a hospital with a 50 percent C-section rate, they don’t see their own chances of having a C-section as being 50 percent. Our research suggests they see it as an abstraction.

Is it fair to say that a lot of women still have no idea that they can obtain C-section rates from prospective hospitals — either by asking or by researching websites like Consumer Reports or The Leapfrog Group — and compare them to industry or geographic norms?

I think most people don’t know to look in the first place. But our study reveals that even if you tell them, it’s not clear it’d translate into different decisions. And it’s not that they don’t care. It’s that the way they value care and the way we report on care are disconnected. When we pick restaurants on Yelp, we’re not picking our waiter or chef. We understand that at restaurants that you could have the best ingredients and menu, but something about the management can lead to a bad meal. We trust restaurant-level reporting, but that’s not the case with hospitals.

Why?

My industry hasn’t yet made that case well. We’re really early in trying to measure quality in health care in consistent ways. There’s billions of dollars in Silicon Valley that could be used to make a Yelp for health care.

If you were advising a newly pregnant loved one about how to choose a medical provider and a facility at which to plan her delivery, what single piece of advice would you give her?

It’s worth looking at the C-section rate — in particular, asking about the rate for low-risk women. Nearly every hospital collects that information, so it’s a reasonable question. And if it’s way out of whack, it’s worth asking some follow-up questions. It’s a very personal choice, but that should be on the list.

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  • Your 3% v 1% complication rate is inaccurate. The complication rate for vaginal delivery is wildly under reported. They don’t include resulting lack of sexual arousal, lifelong incontinence, pain, etc. This entire article is bogus. Shame on you for lying to women. Ps. C sections result in the lowest maternal and fetal deaths compared to vaginal births.

    • Thise side effects you mentioned are not due to vaginal birth but due to unnecessary interference with the birthing process. Directing women not to push when they feel they should. Telling women to push when they have no urge to push. These things cause the side effects you mentioned. Far too much interference and meddling in an otherwise very straightforward process

    • I agree with Emily it is impossible to effectively count Pelvic Floor trauma from vaginal delivery without separating those who had medicated deliveries, those who had coached pushing with lithotomy position, those that were given episiotomies, those that were told they needed the baby out by a specific time (it happens especially when a hospital is busy), and especially those with an assisted delivery employing use of a vacuum or forceps. The stats are very different when a woman is not resigned to deliver in bed, can push as she feels the urge not when she is told (often by someone who doesn’t have the experience of giving birth i.e. Male OB) and doesn’t understand that women know exactly how best to push on their own, and when time isn’t an issue. I’ve seen women in second stage with zero tears and trauma push for 15 mins and some push for up to 7.5 hours (both examples were hospital deliveries). These women had care providers that were hands off as ACOG now recommends for low risk women.

      Brian are you not considering diastasis recti a complication? Every woman who receives a cesarean will have a life long separation created from the surgical procedure. This can create Pelvic Floor issues many months and sometimes years later postpartum. It is not only under reported and overlooked it is also considered unrelated by many care providers that lack a deeper understanding of kenesiology.
      This could be avoided by not only approximating the lower rectus muscles after closing the uterus but also stitching them back together along the torn linea alba. OBs tend to be very messy surgeons that value speed over precision. Some even compete with how fast they can get in and out.

      That said the USA has the only rising maternal fetal death rates in the developed world. So the country spending the most is over managing birth, thus the push for ACOG to encourage less intervention. Over 14% of maternal deaths are from cardiovascular disease and guess what? We have the same rate of deaths according to the CDC when it comes to sepsis! Why are these women dying from sepsis? It isnt from vaginal deliveries it is from surgical deliveries. We might want to cover it up or push it under the rug but responsible care providers provide CARE and try to change their practice according to what is evidence based. What is evidence based is not always what you learn in med school and not always what is routine at a hospital that may employ you. There are some amazing care providers making waves and changing practices to help save lives. Cesareans are major abdominal surgery it was and is not the safest way. Statistically that is incorrect and it is also a very ignorant position to hold as medical care providers it is our job to believe in the magnificent design of human body not fight and butcher it.

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