Saturday, July 21, 2012 Transparency in Maternity Care 

There's a new website out that I've been wanting to highlight for a while.  Now, as the author struggles to finance her work on the site, it's even more important that I publicize the site.

The site is called and it has the cesarean rates for most of the states in the U.S. and the provinces in Canada.

Most importantly, not only does it have the cesarean rates by state/province, it also has the cesarean rates by individual hospital.

Earthy-birthy types who read my blog probably already know about this wonderful resource, but others may not.  It makes for very interesting reading and I recommend the site.

Having cesarean rates available by hospital is incredibly useful information.  If you live in an area where you have the choice of more than one hospital, you can see which ones have very high baseline cesarean rates and which ones don't.

Such information has to be interpreted with caution, of course, since some hospitals have higher loads of high-risk patients who might be expected to have higher cesarean rates. This is a legitimate concern.  However, even among hospitals that serve higher-risk patient populations, cesarean rates can vary widely. So while caution has to be used when viewing this data, it still can be useful to the consumer.  Some hospitals really do have a strong climate of overutilization of cesareans, and consumers should have access to that information before choosing to become a customer of that hospital.

So let's talk a little bit more about the variations in cesarean use and the importance of transparency in cesarean rates for quality control purposes.
Image Use Disclaimer: I received express permission from creator Jill Arnold of The Unnecesarean to use the images. If you want to use them, please ask her permission first.
Variations in Cesarean Utilization

One of the attitudes we have to fight against all the time in Cesarean Awareness advocacy is the common public perception that cesareans are only done when necessary.  In other words, most people assume that if a woman had a cesarean, it was usually because she needed it and it saved her or her baby's life.

Yes, cesareans can be life-saving, and there is no doubt that having them available is a wonderful thing.  Absolutely no argument there.

However, while cesareans mostly used to be used only when truly needed, there are many cesareans being performed today that are not medically indicated.  And the strong regional variations in cesarean use just reinforce this.

Below is a chart from Jill's site of the ten hospitals with the highest c-section rates in Florida.

Now look at a chart from Jill representing the ten hospitals with the highest c-section rates in Utah.

So the hospital with the highest cesarean rate in Florida has a rate TWICE as high as the hospital with the highest cesarean rate in Utah.

Come on, are the uteri of women in Utah really that much more efficient as the uteri of women in Florida? No, of course not.  The fact is that cesarean rates are highly variable by region, by hospital, and by doctor, and many of these variations are not explainable by demographic differences or risk caseload.

Even within one regional area with similar demographics and patient risk profiles (and eliminating cesareans for indications like breech, thought to be "necessary" by some providers), cesarean rates can vary widely.

While doctors like to blame women for high c-section rates (the overused "women are too old or too fat" or "women are requesting these cesareans" arguments), the truth is that provider practice patterns have far more influence on cesarean rates than factors attributable to women themselves.

The Childbirth Connection, an organization devoted to improving maternity care, confirms this trend:
The cesarean rate varies broadly across states and areas of the country, hospitals, and maternity professionals. Most of this variation is due to "practice style" rather than differences in the needs and preferences of childbearing women.
In other words, your chances of "needing" a cesarean at one hospital in your area may be quite different than your chances of "needing" a cesarean in a different hospital in your area.  Even if you fall into a supposedly "high-risk" category, your chances of "needing" a cesarean can vary widely, depending on who you see and their practice patterns around birth.

While some cesareans truly are prudent and at times even life-saving, many cesareans performed today are not.  Women deserve to know which hospitals have high rates of cesarean utilization and which do not, so that they can make informed choices about where they go to birth, should they choose to have a hospital birth.


I would like to tell you that hospital-level cesarean rates area available for all 50 states, but alas, that's not true.  Last I checked Jill's site, the following states did not have hospital-level information about cesarean rates available:
Why is this information not available uniformly? The reasons vary. Some states don't think consumers are interested in this information and so don't provide it. Or pencil-pushers decide that providing cesarean rates to the public is not a Department of Health budget priority.  A few states have decided that health consumers have no right to this information and refuse to release hospital-level cesarean rates, despite many requests to do so.

There is information in each of the links above on how to contact these states directly to request that this information be made public.  Sometimes, if a state gets enough requests, they make providing hospital-level cesarean rates more of a priority.  (We were able to do this recently in my state.)

On the other hand, sometimes states actively refuse to provide hospital-level cesarean rates because doctors have actively campaigned to keep these rates private, on the grounds that the public is not smart enough to understand the concept of mitigating factors (like a high-risk caseload, etc.).  Or they simply don't want the bad publicity for their hospitals.

This is ridiculous.

As health consumers, we deserve to have public health information about various hospitals and their quality of care.  And we deserve this information for maternity-related care as well as basic overall care.  

The Importance of Transparency

Transparency is a HUGE up-and-coming issue in healthcare.  As one quality watchdog group notes:
You may not realize there are differences in the quality of care provided by different hospitals. Hospitals are busy and complex places. Every day, hundreds of patients are receiving hundreds of different procedures. Medical mistakes are a leading cause of death each year, causing more deaths each year than car accidents, breast cancer and AIDS. 
There is good news! Hospitals can take steps to prevent mistakes and protect patients from unnecessary injury. Even better, there is information available to help you determine the quality of your local hospitals.
More and more, groups such as and the Leapfrog Group have begun to document basic information on Quality of Care measures, such as which hospitals have high rates of hospital-acquired infections, which have poor overall patient safety, and which have high rates of medical mistakes or medication errors.

However, these quality monitoring efforts are in their infancy.  Some hospitals participate voluntarily, but some actively resist any attempt to shine a spotlight more closely on care practices. Yet experience shows that when substandard results are highlighted and a program is developed to address these issues, outcomes can be improved.

It is important to be careful when comparing results from different hospitals, but even with this caution in mind, transparency in Quality of Care measures can be useful in improving care and patient outcomes.

Transparency and Participatory Medicine are concepts whose time has come.

How does this translate to maternity care?  In maternity care, substandard care translates to high rates of maternal or neonatal infections, high rates of early scheduled deliveries, higher-than-average deaths, and a too-high cesarean rate.

Some hospitals would argue that a high cesarean rate is not a sign of substandard care. The World Health Organization disagrees, noting that high rates of non-medically indicated cesareans translate into a higher rate of adverse maternal outcomes, including admission to Intensive Care Units, blood transfusions, hysterectomies, and maternal deaths. Other risks include blood clots, wound infections, anesthesia accidents and other problems.  Clearly, overuse of cesareans has risks.

There is an ongoing argument over what the "most optimal" cesarean rate should be, but that's beside the point.  Whatever the "ideal" rate is, women deserve to know the baseline cesarean rate of their hospital of choice, and how that compares to other hospitals.  Then it is up to them which hospital they choose.

Final Thoughts is a powerful new tool for healthcare consumers.

One of the many useful things on the website is the listing of the cesarean rates of all the U.S. states (both alphabetically and by highest-to-lowest rates). There is also a graph showing the increase in cesarean rates over time in the U.S.  Rates from the Canadian Provinces are available as well.

I like the Top Ten slideshow, where slides from several representative states list the hospitals with the highest cesarean rates in those states.  You'll see that quite a few hospitals have c-section rates around 50%-60%, while other states' rates are not nearly so high. This is a good micro-demonstration of how much variation there can be in cesarean rates from hospital to hospital and state to state.  (Click on the page number on the bottom to freeze a particular state's slide.)

Another useful thing is a state-by-state listing of the VBAC ban policies of individual hospitals.  This information can already be obtained from the International Cesarean Awareness Network’s VBAC Policy Database but it's useful to have it all in one place with the hospital-level cesarean rates.

You can read more here about why Jill Arnold created this new site: is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus. The initial goals of the site are to a) show the (poor) quality and inaccessibility of hospital-level information available to the public, b) to assess whether there is public demand for this information and c) to work toward establishing a precedent for hospital data transparency.
How might this site be useful for a typical healthcare consumer?  Jill elaborates on that question here:
As with everything pregnant people can get their hands on, it is one of many tools. Everyone makes decisions differently and weighs things based on their unique experiences, values, preferences and education. For example, a 60% total cesarean rate might trigger a different reaction for different people. A woman that passionately wants to avoid an unnecessary cesarean section might be deterred from giving birth there, while one hoping for an elective primary section might infer something about the culture of the hospital and seek a provider that delivers babies there. Another person might try to evaluate what exactly that means and start investigating why it is so high, while someone else might not care one way or the other where they give birth as long as they are with a care provider they like. 
Ideally, it would be nice to see the site used by pregnant people for the purpose of seeking preference-sensitive care and opening up dialogue with their provider about what they can expect at the hospitals at which their provider has privileges.
If you want to know more about how cesarean rate information is reported. watch the following short video on the technical aspects of such data collection.

Go, check out If you get an additional moment, go to its Facebook Page and "like" it as well.  Blog about it and pass on the link so more people know about this invaluable resource.

And if you can, donate to the author so she can continue carrying on this work.

Thank you, Jill, for your hard work on this site.  Brava!


Health Aff (Millwood). 2006 Sep-Oct;25(5):w355-67. Epub 2006 Aug 8. Geographic variation in the appropriate use of cesarean delivery. Baicker K, Buckles KS, Chandra A.   PMID: 16895942
There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristics but are greatly influenced by nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure. Areas with higher usage rates perform the intervention in medically less appropriate populations-that is, relatively healthier births-and do not see improvements in maternal or neonatal mortality.
Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL, et al.   PMID: 17547880
OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.
Obstet Gynecol. 2010 Jun;115(6):1201-8. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Hanley GE, Janssen PA, Greyson D.   PMID: 20502291
OBJECTIVE: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery. METHODS: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839)...RESULTS: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries. CONCLUSION: Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.
Birth. 2005 Sep;32(3):170-8. Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Mahoney SF, Malcoe LH. PMID: 16128970
BACKGROUND: Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations...METHODS: We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999... RESULTS: The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03). CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.


Shirley Stark said...

This is a great resource.. thank you for sharing. I had to choose between three hospitals (Northern VA), and we did wind up choosing one that did have a fairly high rate of cesareans but they have the most high-risk pregnancies (in fact, most of the surrounding hospitals transfer anybody there if they are suspected to be high risk). Aaaaand then I wound up having a c-section.

It was not planned but in the end I am okay with how everything went because there were dangers that presented themselves that we had not anticipated. My doctor never rushed anything and I had time with my doula and my husband to come to our decision, so ultimately I was glad I was in a place that I could feel comfortable knowing that whatever choice was made I would be well cared for. Unfortunately, I realize that is not a situation that every woman finds themself in...

Mich said...

Thank you for this resource. I checked and the hospitals in Alberta in and near my city have less than 30% c rates, but very low VBAC's (~10%).