Does the hospital where someone gives birth impact their chances of having a cesarean birth? Consumer Reports has raised this very question following an investigation into the c-section rates at hospitals across the country. We talked with Doris Peter, PhD, Director of Consumer Reports’ Ratings Center to find out more about their survey, the findings, and why they are interested in cesarean rates (doesn’t Consumer Reports rate toasters?).
About the Report
Consumer Reports surveyed more than 1,200 hospitals to ask about their cesarean rates and their plans to achieve the U.S. Department of Health and Human Services target cesarean rate of 23.9%. The investigation asked specifically about low risk women – healthy mothers expecting one child delivering at full-term with the baby in the head down position. The results are fascinating — some hospitals are at or below this level and others are well above. Trends were seen in what part of the country hospitals were located with those in the West and Midwest at or below the target rate. Nationwide, 40% of hospitals have achieved the national target from the Department of Health & Human Services including both large and small hospitals. To interpret and understand the results, Consumer Reports reached out to well respected resources in the maternity care field including the California Maternal Quality Care Collaborative and Dr. Neel Shah, an obstetrician and professor at Harvard who gave a keynote presentation on cesarean rates at the 2016 DONA International conference.
Consumer Reports Resources on Cesarean Rates
Your Biggest C-Section Risk May Be Your Hospital (Apr 2016) – describes the research and findings with highlights of the results including lists of hospitals with high and low rates
11 Hospitals to Avoid if You Don’t Want a C-Section (June 2016)- Follow-up article with a shorter summary of the findings with links to the responses hospitals submitted to Consumer Reports about their rates
Hospital Ratings – Avoiding a C-Section – PDF version of the entire ratings list
Why is Consumer Reports interested in Cesarean Rates?
Overall, Consumer Reports has a broad interest in overuse of treatments, drugs, tests, and procedures, Peters tells us. They are also interested in helping people make wise decisions about their health care. Cesarean rates impact safety and costs – areas that Consumer Reports considers in all of their reviews. The publication also has a desire to hold decision makers accountable and let them know that consumers are aware of what’s going on in the hopes of creating a dialogue.
That nationwide data for hospital cesarean rates is not published was a significant factor in Consumer Reports’ taking on this investigation. The Joint Commissions, a non-profit organization which accredits hospitals and health systems, collects data for hospitals with more than 300 births per year (the threshold prior to 2016 was 1,100 births) but they don’t publicize the results. Some states calculate their rates themselves, but most don’t. “This is the most important measure. Neither hospitals, doctors or patients are served when we don’t have the data.” Peters said.
Consumer Reports was able to access the data submitted to The Joint Commission via an organization called Leapfrog. The data was analyzed to look for trends and to make comparisons. Consumer Reports then followed up with 11 hospitals with rates that were 10% higher or more than the national target and five large hospitals with the lowest rates. The idea was to find out what those with high rates plan to do about them and learn from those who have the lowest rates. While not all the hospitals provided a response, those that did offered some interesting insight.
Different Perspectives: Themes Emerge from Hospital Responses
When reading the hospital’s responses, differences in language related to efforts to reduce the cesarean rate are very apparent. Those with higher rates use wording such as “discuss”, “consider”, and “encourage” related to reviews of cesarean birth data and feedback to physicians. Those with the lowest rates use much stronger language like “mandated”, “hard stop”, “strict protocols”, and “must.”
Response from hospitals with the lowest rates also included multiple people involved in case reviews or committees so many eyes are reviewing the data. In many cases people at different levels of the organization are also reviewing the data. Those with higher rates tend to rely on one person to review cesarean birth data to find trends to address, opportunities for improvement, and communication of findings to both physicians and the hospital.
Another notable difference between hospitals with high rates versus low was the mention of midwives. Those with c-section rates of 36% or more that responded to Consumer Reports indicated that care was provided by physicians almost exclusively. This is a sharp contrast to those with rates of 13% or less who note the important role of midwifery care at their hospital. It’s important to remember that the Consumer Reports investigation focused on low risk mothers with a singleton, vertex baby at full term.
Hospitals with low rates indicated that their work to reduce the number of cesarean births has been on-going for years, even decades. They also go to great lengths to communicate cesarean rates – posting them publicly and providing them to physicians frequently for accountability. This indicates that reducing the cesarean rate is part of the overall culture at these hospitals, not a bullet point in an organizational improvement document collecting dust in the risk management office. Hospitals with low cesarean rates are committed to it. They work at it – over long periods of time and talk about it throughout the organization.
Language, data review processes, inclusion of midwives and long term dedication to vaginal birth indicate strong differences in the commitment and focus given to reducing the cesarean rate. The results are clear, though, hospitals that commit greater internal resources to reviewing their own cesarean birth data and take a stronger position on their own protocols perform fewer surgical births.
In contrast, hospitals with higher rates consistently attribute this to serving high risk population. Yet the data doesn’t bear this out.
Much of the conventional wisdom for why rates have increased points to mothers—but that conventional wisdom doesn’t bear out, Shah says. “Some people say moms are older, there’s more diabetes, there’s more hypertension, there’s more obesity, there’s more IVF, there’s more twins—but all of that collectively only explains a small amount of the increase over time,” he says.
— Your Biggest C-Section Risk May Be Your Hospital, Consumer Reports
The Myth of Maternal Request
The idea that women are electing to have a cesarean for their own reasons rather than out of medical necessity has come up again and again when cesarean rates are discussed despite the fact that data does not support maternal request as a significant factor in the rise in cesarean rates. One hospital’s response to Consumer Reports said there were “many factors that impact a woman’s decision to have a cesarean section.” Does this perpetuate the maternal request myth? Does this hospital feel patients are the ones deciding whether a baby is born via cesarean or vaginally? Given the power dynamic between doctors and patients and the high cesarean rates at certain hospitals this seems a bit like pushing the problem of too many cesarean births off on the patient. While patients do have to consent to the surgery, most mothers telling their birth stories say, “….so I had to have a c-section” not “…so I chose to have a c-section.” Consumer Reports addresses the myth of maternal request directly saying:
Neither does patient demand appear to be behind the rates. Less than 1 percent of 1,314 new mothers actually asked for a C-section without a medical reason for it, according to a survey conducted by Childbirth Connection, part of the nonprofit National Partnership for Women and Families, that focuses on improving maternity care in this country.
In the U.S. far fewer babies are born on holidays such as the Fourth of July or days around Thanksgiving or Christmas, we found when we examined three year’s worth of data on births compiled for us by the Centers for Disease Control and Prevention. That occurs partly because hospitals tend to schedule C-sections and inductions for when they are well staffed, Shah explained.
— Your Biggest C-Section Risk May Be Your Hospital, Consumer Reports
What can doulas do?
Promote the role of doulas in your community. We know that doula support helps reduce the chances of cesarean birth. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine’s joint statement on reducing the primary cesarean says that doula support is one of the most effective ways available. CMQCC’s Toolkit to Support Vaginal Birth and Reduce Primary Cesareans also includes doula support. And hospitals are taking note. In their response to the Consumer Reports survey, Winthrop University Hospital included doulas as one of the specific remedies they have already put in place to address their cesarean rate
Share available information on cesarean and VBAC rates with clients and your community. Social media and blogs about this data can help increase awareness.
Inform clients of risks and benefits of a cesarean birth. When something becomes commonplace, we become more accepting of it. This is simply human nature. At this point in our culture, cesareans are not a rare or shocking outcome. This means that we, as a society, are more likely to accept this result and far less likely to question it. As doulas, we have a responsibility to share evidence based information so that families understand the risks involved for a cesarean birth for mother and baby.
Encourage patients to ask physicians about their individual cesarean rates. When we spoke with Consumer Reports, this was one of their recommendations for how doulas can help address the cesarean rate. They believe strongly that when consumers, in this case your clients, ask for information it creates a culture of accountability. Think what could happen if every pregnant woman asked her doctor for their cesarean rate! In many communities there is competition for maternity patients among providers and hospitals. If cesarean rate became a significant and known factor for a woman’s decision on who she chooses for her care, we are more likely to see hospitals and care providers make a stronger commitment to reducing their rates for healthy, low risk women giving birth at full term to a single, vertex baby.
— Adrianne Gordon, MBA, CD(DONA), Blog Manager