Avoiding a c-section is probably a big part of your birth plan. But even the best laid plans go can go awry during labor, and you’ll probably defer to your doctor and the hospital staff. The problem? A new report shows hospitals across the country are on very different pages when it comes to making the judgment call for a c-section.
Consumer Reports looked at over 1,300 hospitals across the US to see how their c-section averages compared to the national c-section average. And while 32 percent of American women are having c-sections every year, they looked through an even narrower lens, only accounting for women expecting one child who is full-term and is positioned head first. For these moms-to-be, the national average c-section rate is 25.8 percent.
The goal, for both health professionals and pregnant women, is to lower this number. For example, the Department of Health and Human Services has set the national target for these low-risk pregnancies at 23.9 percent. But that number should never drop to zero.
"We don't want a cesarean rate of 0 percent," Rebekah Wheeler, RN, CNM, MPH, tells The Bump. "The World Health Organization found 10 to 15 percent of labors need to be delivered via cesarean in order for moms and babies to be healthy. If you or your baby need a cesarean birth, please know how very lucky you are to be in a time and a place where you can safely have one. But also do the legwork up front to ensure that you are having your baby with a team of providers whom you trust to help avoid a surgery you don't need. Then, if they're recommending it in the course of your care, you can trust their opinions and trust your own experience that this was what had to happen, and that giving birth via cesarean is the right choice for you and your baby."
Consumer Reports shows we have some work to do before all moms can feel confident in their providers.
How many hospitals are performing too many c-sections?
In short, more than half. Six out of 10 hospitals had c-section rates above the national low-risk target of 23.9 percent.
And geography matters, to an extent. In general, rates are lower in hospitals in the west and midwest.
States with the lowest c-section risk:
- South Dakota (17 percent)
- Ohio (17 percent)
- New Mexico (17 percent)
- Minnesota (18 percent)
States with the highest c-section risk:
- West Virginia (31 percent)
- Florida (32 percent)
- Louisiana (32 percent)
- Nebraska (34 percent)
“Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non–medically indicated cesareans being done,” says Aaron B. Caughey, MD, chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine. “That’s not good medicine.”
Why the rise in non-medically indicated cesareans?
No, it’s not that more women are asking for them. It’s that many hospitals are busy and understaffed. If labor is taking a long time, doctors may call for a c-section to free up more beds. This year, ACOG pledged to encourage OBs to help mothers labor how they want to, but instituting this policy will take time.
Additionally, technological advancements can inadvertently cause more worry. Take fetal heart rate monitors, for example. Consumer Reports says that they only identify an actual problem 15 percent of a time. But concerns about heart rate can lead to needless intervention, like a c-section.
What can you do about it?
If you live in an area with multiple hospitals, it pays to do your homework. While certain states have higher c-section rates, there’s also a lot of variation on a local level, even within the same network. Wheeler suggests asking your provider three questions:
- "What are the most common indications for cesarean in their practice? (Breech and fetal stress are great answers. Patient preference and big babies are bad answers.)"
- "What do the providers in the practice do to reduce c-sections rates? (Good answers: Avoid unnecessary inductions, give women lots of time and not use strict labor curves, help people move and change positions throughout labor, have patience, manually rotate malpositioned fetuses.) If the provider's answer is vague or evasive, that is a sign you might want to deliver somewhere else."
- "Ask what the epidural rate is for the practice. Not that epidurals cause cesareans (studies truly show they don't overall), but it is a proxy for a practice being open to low-intervention care, which is linked culturally to low cesarean section rates."
Ask your OB these additional questions:
- "Ask your OB provider for both their own and their group's c-section rate. (I say group, because at this point almost all OBs/CNMs take on-call teams who don't practice at all alike). If an OB can't answer this, it's a red flag because it means they aren't tracking c-section rates. Every practice in the country should be on board with reducing c-section rates at this point; it is so ubiquitous in the OB-care conversation."
- "If it is high, ask if they see very high-risk patients a lot. If yes, this could be why. If no, transfer. Also, if the practice sees high-risk and you're low-risk, you might want to transfer simply because it is very hard to get low-intervention care at a high-risk center. They're so used to using interventions that they have a very hard time, in culture and practice, with not intervening."
In the meantime, Consumer Reports has combed through the largest hospitals in the US, ranking them by highest and lowest c-section rate. You can see the comprehensive list here.