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.
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.
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.
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.