The Push to Reduce Unnecessary C-Sections

Photo: UMHealthSystem (CC)
By Amie Newman |

Special thanks to Rachel BremanAmy Romano, and Carol Sakala for their work on this post.

While cesarean sections are sometimes necessary and even life-saving, in most situations, spontaneous vaginal births are safest for both women and babies. That’s just one reason why we’re celebrating California’s game-changing new commitment to reducing the number of medically unnecessary C-sections.

The state’s insurance exchange, Covered California, recently announced that insurers in the exchange will not be permitted to provide insurance coverage for hospitals with high rates of C-sections — specifically those with rates above 23.9% in low-risk women giving birth for the first time. The new contract with insurers also requires them to adopt a new payment structure with hospitals that ensures there is no financial incentive to perform C-sections.

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Covered California’s efforts to reduce the number of C-sections among low-risk women align with the federal government’s push, through the Healthy People 2020 initiative, to do the same. The World Health Organization (WHO) discourages aiming for a target rate. In a statement last year the WHO relied on new studies which reveal that when rates of c-sections are closer to 10 percent, maternal and newborn deaths decrease. But when the rate rises above 10 percent, mortality rates don’t improve. Therefore they recommend focusing on the needs of each individual patient and performing c-sections only when medically necessary.

Covered California’s new policy signals good news for women’s health and for families’ bank accounts. By shining a light on the nation’s too-high C-section rate, the requirement also encourages deeper discussion about how hospitals can better support healthy pregnancy, labor, and birth, especially in low-risk women. It opens the door to offering women more and better support for decision-making about childbirth care and allows the conversation about the benefits of midwifery care for normal, low-risk births to expand.

It also addresses the profit-making incentives for hospitals. C-sections can be as much as double the cost of vaginal births. A report commissioned by Childbirth Connection and partners, “The Cost of Having a Baby in the United States,” documents the results of a study on charges and payments for maternal and newborn care. The study found that combined payments for maternal and newborn care were 50 percent higher with cesarean births versus vaginal births, for both commercial insurers and Medicaid.

While most mothers and babies who have cesarean births do fine, cesarean sections involve more risks than spontaneous vaginal births. Women who have cesarean sections are more likely to have more infections after the birth (usually in the uterus, bladder, or incision, and including infections resistant to antibiotics), more pain, longer recovery periods, and a greater chance of being re-hospitalized. A woman who has had a cesarean section is more likely to have a cesarean section in future pregnancies. As the number of cesareans increases for a woman, the risk of complications in future pregnancies, especially placental problems, also increases.

Infographic courtesy of California Health Care Foundation

Infographic courtesy of California Health Care Foundation

That’s why the climbing rates of C-sections in this country are concerning. In 1970, five percent of babies were born via C-section in the United States. Today, one out of every three women gives birth via C-section. According to HCUP, it’s the most common operating room procedure for women of reproductive age.

And it’s not because more women are “requesting” the surgery. Despite some media implying that women are “too posh to push,” Childbirth Connection’s Listening to Mothers survey of over 1,500 mothers found that very few women actually “request” C-sections.

It’s also not solely because pregnant women, overall, have become older and heavier, both of which can contribute to a higher risk of undergoing a C-section. Or because the fertility treatments more women are using lead to more births of twins or triplets, which often require C-sections. Rates have gone up among all populations of women regardless of age, income level, the extent of their health problems, race/ethnicity, and the number of babies they are having.

Rather, because of a range of issues — including limited awareness of both the short and long term harms of C-sections, a low priority put on enhancing women’s own abilities to give birth (how many women know that you don’t need to induce labor before the 42nd week of pregnancy, the standard of care in other countries if the pregnancy is healthy) and the refusal of many hospitals to offer the informed choice of vaginal birth (especially after a woman has had a previous birth via C-section) — many women end up with unnecessary C-sections.  A Consumer Reports analysis of first-time mothers with low-risk pregnancies, found that almost half of C-sections performed are done in situations when babies could be safely delivered vaginally instead.

Consumer Reports puts the cause of our increased rates of C-sections in even simpler terms:

While a number of factors can increase the chance of having a C-section—being older or heavier or having diabetes, for example—the biggest risk “may simply be which hospital a mother walks into to deliver her baby,” [emphasis mine] says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in this country and around the world.

The type of provider a woman chooses also can play a role. Midwives are trained to promote physiological childbirth, provide high quality care and often have fewer patients who need a cesarean. Physicians who work collaboratively with midwives also tend to perform fewer cesareans.

In the majority of hospitals in the U.S. (60 percent), a woman who comes in to give birth will have a higher than necessary risk of giving birth via C-section. But the rates vary dramatically from hospital to hospital. In California, some hospitals report a 12 percent C-section rate and others a stunning 70 percent rate for low-risk births.

Covered California is taking its cues from this growing body of knowledge. The policy change plays an important role in helping to shape a new vision for women’s choices in childbirth. One where the hospital a woman births in does not determine the type of birth she will have. If hospitals with high C-section rates are being compelled to examine their own health care practices and whether the traditional “medical model” of care is harming or helping laboring and birthing women, the hope is that a new conversation about the benefits and challenges of different models of maternity care (and new voices–of midwives and doulas) will emerge and be given a larger platform.

Women need access to as much information and support as necessary to make informed decisions about their own labor and childbirth. In the midwifery model of care, the majority of pregnancies, labors, and births are assumed to be “normal, biological processes that result in healthy outcomes for both mothers and babies.” In the medical model, the focus is on  “preventing, diagnosing, and treating the complications that can occur during pregnancy, labor, and birth.”

There is incentive. California-based Kaiser Permanente uses midwives in its hospitals and has some of the lowest C-section rates in the state, according to Modern Healthcare.

Covered California’s new move to exclude hospitals with high C-section rates from coverage is a unique way to compel those hospitals to take a long, hard look at themselves, their health care practices, and their profit-making incentives. Amy Romano, SVP of Baby + Co, explains:

Payers are looking specifically at the c-section rate in low-risk women. This means the policy is not aimed at women who need c-sections for medical reasons. It’s not actually aimed at women at all. It is designed to help hospitals looks at their policies and practices and focus on safely reducing c-section rates. Many hospitals are doing this now and bringing their low-risk c-section rates down with programs like providing doula services, having more patience with slow labors, and reducing unnecessary inductions of labor. This policy will help more women choose hospitals that are implementing these and other evidence-based practices.

The number of women dying during pregnancy and childbirth is increasing in the United States. We know higher C-section rates are not saving lives.

The goal is to find a balance, says pediatrician Ana Langer, professor of the practice of public health and coordinator of the dean’s Special Initiative in Women and Health at the Harvard T.H. Chan School of Public Health, when it comes to standardizing hospital care. Women need to be allowed to have normal deliveries with minimal interventions and feel confident that hospitals will be ready to address any unexpected emergencies, should they arise.

All women, regardless of whether they need a C-section or birth vaginally, deserve greater autonomy and control over their birth experiences. For this to happen, women need access to the full spectrum of facts and information that will allow them to make the best decisions for themselves during pregnancy, labor and birth including increased choice and understanding of the models of maternity care available, the costs related to C-sections and vaginal births, and how medical interventions may impact the kind of birth they are able to have.

A woman’s risk of undergoing a medically unnecessary C-section shouldn’t dramatically increase or decrease depending upon the hospital or health care provider she uses. Covered California has created an opportunity to address this stark reality by letting hospitals with high C-section rates for low-risk women know their medical and financial practices need to change in order to provide the best possible care for women and newborns.

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11 Comments

  1. Thanks for this great story. We definitely want to track how this initiative unfolds in California. As well, to help hospitals achieve the desired NTSV Cesarean rate of 23.9% or lower, California Maternal Quality Care Collaborative will convene two statewide collaboratives of about 35 hospitals each, to implement our newest Maternal Quality Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (www.cmqcc.org/VBirthToolkit) This tool is free to download. We encourage advocates and women to ask their local hospital if they know about the toolkit and encourage them to get it and implement it in their birth units.

  2. Jane Pincus says:

    These are valuable facts, and Covered California has taken important steps to decrease the number of cesareans unnecessarily performed. I look forward to hearing about the processes that must take place for changes to occur.
    But the article oddly lacks any mention of the doctors responsible for performing these operations, or of the training that they undergo.
    As an informed and dedicated brigade of childbirth activists (too many to mention here) have noted for decades, and as we wrote in the “Our Bodies, Ourselves” of 45 years ago and in subsequent editions, modern obstetricians rarely if ever see a normal birth. Of course they are needed in certain instances (re: the WHO report). Yet they are still calling most of the moves in medical settings, despite the welcome increase in midwifery and doula care — despite the ‘best scientific evidence’. A ‘climate of doubt,’even one of ignorance and fear, is rampant, for a multitude of reasons.
    Until the EDUCATION of ob/gyns enlarges its focus; until an equality of power between doctors and midwives develops; until pregnant women take advantage of the available amount of information regarding cesareans; until women regain confidence in giving birth normally and medical protocols are altered so that childbirth is regarded as an event of health and a celebration of life — until a radical change happens — but how? — I feel pessimistic that much change is possible. At the same time, I heartily admire and support all those who are working so hard to protect and foster the health and happiness of birthing women.

    • Amie Newman says:

      Thank you, Jane! I agree that all of this is needed. I thank you for your excellent comment and clearly we need to continue writing about this from different angles so that we uncover all of the ways in which we can make a dent in the way we view and treat childbirth.

    • Kitty Ernst says:

      Yes Jane, You are right.

      But also….Why are we paying for OB residencies programs and not midwifery residency programs with our tax dollars??? We should be training 4-6 midwives to every surgical specialist. Midwifery is not obstetrics and obstetrics is not midwifery. BOTH are needed but in ratios that match the needs of the women we serve. It is not rocket science!

  3. bobknuppel says:

    We must lower c/sections. The greatest motivator will be monetary consequences as initiated in California. Of course, one could consider paying more for labor management (just move the bucket of money).
    The positive predictive value for a Category 3 fhr and cerebral palsy is <1%. Who would want that low a positive predictive value for any test.
    I trained when c/s were 7% and the cp rate has not changed since then. It is my contention that the high c/section rate is associated with the increased mortality and morbidity for women.
    One longs for the "granola' days and supportive natural childbirth which I experienced with the
    original authors in Boston. Fortunately, I had the pleasure of working with bright, progressive female residents and they pushed for many positive changes during my residency.
    This calls for a big cultural change which will take at least a decade based on previous experience. The education of physicians and labor nurses is mandatory regarding natural childbirth. The patients need reliable and truly accurate information to make appropriate decisions. Implementing these philosophies (non-existent for at least 25 years) will require the implementation of myriad changes meet by resistance. Effecting change takes experience and use of systems such as Lean to address "WHY" and what are the root causes of the increased M&M and c/section rates.
    Time will tell, but experienced, non-conflicted leadership is required to show the way.

    • Jane Pincus says:

      Yes, Kitty, I agree that a significant increase in midwifery programs is essential to any change. And it does boil down both to the ‘money trail’ and also to the related questions: Who has the will to change the status quo, the power? Who has the most to gain, to lose?

      I am most curious about how the California initiative will affect physicians’ practices and hospital protocols. Which mechanisms will succeed in persuading, convincing, compelling change? Which will fail? I hope that the processes and results will become available in a timely way, so that we can learn from what has occurred.

      For the most part (always respecting the necessity of obstetrical training and medical attention in certain situations) obstetrical careers are not directed toward the kind of fully woman-centered care which, as this article states, has been proven to be so much healthier and more beneficial for women and babies..

      Another question: How can professionals UNLEARN the present dependence on technology? We understand how and why attitudes and practices become more medically oriented. But wouldn’t It be interesting to create a series of discussions between those medically trained practitioners — nurses, doctors AND midwives — who have been able to ‘unmedicalize’ their thoughts practices, goals. Why did they want to change? What evnt or insight altered their attitudes? Michel Odent, in his Pithiviers clinic, did address this ‘undoing’ process in his book ‘Birth Reborn;’ I found it fascinating.

      But then, there’s the fact that women too are captives of technologically dominated prenatal and birth care regulations, from the beginning to the end of pregnancy (being scheduled for at least four ultrasounds during a normal pregnancy to births prematurely induced before 42 weeks — and so on). Articles and childbirth books document their experiences; we learn how their expectations are met, disrupted, renegotiated or destroyed, and how they learn from them, and change.

      There’s so much to say, still, over and over again.This constant necessary work to improve childbirth takes the form of measured, informative articles like this, written by seasoned childbirth advocates.

      For more information, be sure to read BIRTH: Journal of Perinatal Issues, which for decades has described and catalogued innumerable studies and initiatives directed toward bettering the birth experiences of women and children.

      I share Bob Knuppel’s wish for the atmosphere of the 1970s, when so much seemed possible, when an important ‘window’ in time opened to bring midwifery practices, beliefs and wisdom alive again in the U.S. Wouldn’t it be wonderful to create a unified, colorful, focused and effective women’s birthing movement, vehement and powerful, with a clearly enunciated vision of woman-and-family centered birth?

      • Jane Pincus says:

        Also, a really helpful book:
        The Medical Delivery Business: Health Reform, Childbirth and the Economic Order
        Barbara Bridgman Perkins
        Rutgers University Press
        New Brunswick, New Jersey, 2004
        252 pp, $42.95

  4. Steve Calvin says:

    Great article and very perceptive comments. I agree with my friend Kitty Ernst that financial incentives drive the current maternity care system and that more CNMs need to be trained. Here in MN we are finding success at the Minnesota Birth Center by developing our BirthBundle, a comprehensive midwife-led maternity and newborn package of care for a single price. We now have hospitals and payers on board. Better care will come when we pay for episodes of care rather than a list of procedures. More info is at http://www.theminnesotabirthcenter.com/ and http://www.pregnant-pauses.org/

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