According to a new survey published in the May edition of Consumer Reports, the cesarean section rates among US hospitals vary widely. The survey found that cesarean section rates for low-risk deliveries ranged from a low of 4% to a high of 57%. For example, at Los Angeles Community Hospital, a whopping 55% of pregnant women who are at low-risk (e.g., women who have not undergone a previous cesarean section, are not in premature labor, and are carrying a single fetus in the head-down position) undergo a cesarean section. At California Hospital Medical Center, also in Los Angeles, the cesarean section rate for low-risk deliveries is 15%, while at Western Medical Center Anaheim, 28 miles to the south, it is approximately 11%.
For the survey, Consumer Reports investigated more than 1,500 hospitals in 22 states. Because the ratings were based on the cesarean section rates for low-risk women, the average cesarean section rate was approximately18%, which is significantly higher than the national average of 12.6% in 2000. The average total cesarean section rate, which includes all cesarean deliveries not just low-risk ones and also includes repeat cesareans, is 33%.
The survey also found slightly higher rates at hospitals in large urban areas, compared with hospitals in smaller cities; it noted that this finding might be because they care for more women with risk factors not accounted for in the Consumer Reports’ data or they have a larger proportion of first-time mothers. The study authors note that their ratings were similar to other studies in regard to significant regional differences. The lowest rates were found in the mountain states, the West coast, and the upper Midwest. In addition, for-profit hospitals tended to have higher cesarean section rates.
In March 2014, the American College of Obstetrics and Gynecology (ACOG) issued an Obstetric Care Consensus entitled, Safe Prevention of the PrimaryCesarean Delivery. It noted that in 2011, one in three women who gave birth in the US did so by cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous (no previous deliver), full term, singleton (one pregnancy), vertex (head first) cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency: labor dystocia (failure to progress in labor due to a baby too large for the mother’s pelvis), abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation (position other than head-down), multiple gestation, and suspected fetal macrosomia (unusually large infant). Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate significantly slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version (a maneuver on the mother’s abdomen that rotates the baby to a head-down position) for breech presentation and a trial of labor for women with twin pregnancies when the first twin is in cephalic (head-down) presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.