By Lola Butcher
America’s shameful maternity mortality rate is closely associated with its high rate of Cesarean-section deliveries. Hospitals, physicians and mothers themselves share the blame for the high C-section rate, but employers, payers and multistakeholder state-specific initiatives may be the solution.
C-sections can save lives – both moms’ and babies’ – but unless a medical reason indicates otherwise, a vaginal birth is much safer, according to the National Partnership for Women & Families.
Why? A 2017 systematic review and meta-analysis of 1,328 articles found that women who have a C-section have a higher chance of maternal death and postpartum infection than those who have a vaginal birth. The World Health Organization says, “At population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.”
Yet, the worldwide C-section rate climbed from 12.1 percent in 2000 to 21.2 percent in 2015, according to Global Epidemiology of Use and Disparities in Caesarean Sections published in The Lancet last October.
The U.S. rate? Not good. The Commonwealth Fund’s study of women’s health and health care in 11 wealthy nations found: “The U.S. has among the highest C-section rates, with 320 procedures per 1,000 live births – slightly lower than Switzerland and Australia (327 and 332 procedures, respectively, per 1,000 live births). In Norway and the Netherlands, C-sections are performed at about half the rate, with slightly more than 160 procedures per 1,000 live births. Studies show that an elected C-section can increase a woman’s risk for life-threatening complications during childbirth and subsequent deliveries.” Get the details in this study: “U.S. More Likely to Die in Pregnancy and Childbirth and Skip Care Because of Cost, Multi-Nation Survey Finds; C-Section Rates Rank Among Highest,” which the Commonwealth Fund published in December.
Journalists who cover individual communities will need state- and hospital-level rates, and you are in luck.
State rates. The Centers for Disease Control and Prevention offers this neat interactive graphic that lets you see how your state compares with all other – and how the rate in your state has changed since 2005.
Hospital-level rates. Use the Leapfrog Group’s Compare Hospitals tool to find the C-section rates at local hospitals. Two things to note:
- Leapfrog Group benchmarks hospitals against a C-section target rate that is high by some standards. Here’s the explanation from its website: “With the guidance of its Maternity Care Expert Panel, The Leapfrog Group adopted the cesarean section target rate (23.9%) proposed by HealthyPeople.gov’s 2020 initiative, which seeks to improve the health and well-being of women, infants, children and families by the year 2020.” (Even at the 23.9 percent target, Leapfrog found that more than 60% of reporting hospitals had excessive rates of C-sections.)
- Participation in the Leapfrog Group’s database is voluntary, and most hospitals do not volunteer. The database includes C-section data from 1,339 hospitals, which is less than half of the hospitals that provide labor and delivery services.
The variation in C-section rates at the hospital level can be eye-popping. A June 2019 Harvard Business Review said: “As of 2015, the proportion of C-sections at individual U.S. hospitals varied from 7 percent of births to a startling 70 percent of births. These differences play out by race. For example, 36 percent of births among Hispanic black women are C-sections versus 30.9 percent for non-Hispanic white women – a difference that medical experts consider significant.”
The article, The Rising U.S. Maternal Mortality Rate Demands Action from Employers, was written by Suzanne Delbanco, executive director of Catalyst for Payment Reform, and colleagues.
Delbanco’s organization, a nonprofit comprised of 35 large employers and other healthcare purchasers, has long argued that C-section rates are too high because they are a sweet deal for hospitals and doctors. From its website: “Doctors are paid more for cesarean deliveries than vaginal births – typically 50 percent more. They are also more convenient – the birth can be performed in a shorter amount of time and on a specific date.”
Thus, journalists who write for business or clinician audiences can find some good stories in efforts at payment reform for maternity care. A good place to start is the Center for Healthcare Quality & Payment Reform, which has proposed an alternative payment method for maternity care. From the center’s website: “One of the biggest opportunities for reducing healthcare costs is improving the quality of maternity care. For most businesses, childbirth and newborn care is the largest or second largest (after heart care) category of hospital expenditures, and it’s by far the largest category of hospital expenditures for state Medicaid programs, so even small improvements can result in large savings.”
Other story ideas on the C-section beat:
- Do women care? The American Journal of Managed Care published a study showing that a targeted effort could increase women’s awareness of hospital C-section rates but did not influence their choice of hospital. Check out Does Comparing Cesarean Delivery Rates Influence Women’s Choice of Obstetric Hospital? in the February 2019 issue.
That study, conducted at Ariadne Labs, followed earlier research that women don’t consider hospital quality when choosing the hospital in which they will deliver.
- Does a fear of malpractice claims lead to high C-section rates? Sabrina Safrin, a law professor at Rutgers, debunked that conventional wisdom in The C-Section Epidemic: What’s Tort Reform Got To Do With It? published in the University of Illinois Law Review in 2018.
Lola Butcher writes about health policy and the business of health care. She has written for Undark, Medscape, Neurology Today, Oncology Times, Next Avenue, Managed Care, Modern Healthcare, Brain & Life, Hospitals & Health Networks, Physician Leadership Journal, and HealthLeaders, among other publications. In 2018, she was named one AHCJ’s fellows in Comparative Effectiveness Research, and in 2014, she was chosen for the AHCJ Reporting Fellowship on Health Care Performance.
