For a low-risk, first-time mom, one of the biggest factors in whether she'll have a cesarean birth is the hospital in which she delivers.
In California, C-section rates can vary widely, even for healthy women carrying a single, full-term baby who isn't breech. In hospitals across the state, C-section rates in 2014 swung as low as 12% to as high as 70%.
This week, the California Hospital Assessment and Reporting Taskforce, established in 2004 to track hospital performance, released a large dataset on C-section, breastfeeding and episiotomy rates at individual hospitals.
The goal is to bring California's risk-adjusted C-section rate down to an average of 23.9% by 2020. In 2014, the rate for first-time, low-risk moms was 26.4%.
“There's still wide, unwarranted variation,” said Stephanie Teleki, senior program officer with the California Health Care Foundation. “Really what that's saying is that the hospital is a risk factor. Where you're delivering … can have a big impact on whether you get a C-section.”
The data rated 244 hospitals in the state. Sutter Davis (Calif.) Hospital had the lowest C-section rate in 2014, at 12% of its 598 low-risk, first-time births. At the other end of the spectrum, with a similar number of low-risk patients, Monterey Park (Calif.) Hospital had a 41.6% rate for its 495 deliveries in that category.
“The problem with averages is that they hide variation,” said Julie Morath, CEO of the Hospital Quality Institute, the California Hospital Association's quality improvement arm. “The story of C-sections in California is variation.”
The data looked not at the overall C-section rate, but a hospital's rate among NTSV women, or nulliparous (first-time moms), at term, with a singleton pregnancy, in a vertex, or head-down position.
“This is a really risk-stratified group of women who have the most at stake for having a C-section,” said Brynn Rubinstein, senior manager for transforming maternity care at the Pacific Business Group on Health, a statewide collaborative of healthcare purchasers that's working to publicize the data.
A number of stakeholders are now trying to understand the factors that play into whether women have a C-section and how the procedures can be used most appropriately. The World Health Organization recommends a C-section rate between 10% and 15%, far lower than the U.S. average, which was 32.7% in 2013. C-sections are not only costlier to perform, but carry higher risks for mother and baby.
Moreover, women who undergo a C-section have a 90% chance of having surgery with subsequent pregnancies, especially as only a limited number of hospitals perform vaginal births after cesarean.
One data point researchers noticed is that hospitals in Northern California have a lower C-section rate than those in Southern California. That could suggest a cultural difference. For instance, there could be more demand for natural births in Northern California. Hospitals in that part of the state also are more likely to have midwives attending births, and hospitals that use midwives tended to cluster in the lowest third of the dataset.
“It's also the way birth is managed in a hospital,” Rubinstein said. “The policies and culture come into play. Hospital environments aren't about waiting and seeing. It's high throughput.”
The California Health Care Foundation is helping to fund a workgroup that is addressing the overuse of certain medical procedures, including C-sections. The group includes insurers covering a combined 17 million lives.
One goal is to align the payment model with the desired outcome, whether that's paying a bundled payment for each birth or setting a blended rate for a given population based on a hospital's current C-section rate. Hospitals that perform fewer C-sections will share in those savings and those that exceed the baseline will be on the hook for those costs.
According to the Center for Healthcare Quality and Payment Reform, the average commercial payment for vaginal births was $5,809 compared with $11,193 for cesarean births. Total Medicaid payments for newborn care were $3,014 for vaginal births and $5,607 for cesarean births.
Kaiser Permanente, which operates as both a health plan and a provider, had some of the lowest C-section rates in the state, but it too saw variation. The C-section rate at its Redwood City hospital in Northern California was 16% in 2014, but was as high as 30% in San Diego.
C-section rates also varied widely within a hospital, from physician to physician.
In addition to the payment model, the physician employment model—whether doctors are on staff or in private practice—might make a difference.
“It's a matter of how care is organized and how it's paid,” said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative, the group that released this week's data.
For instance, some hospitals have started to employ “laborists,” or obstetricians who manage care for women while they are in labor and sometimes even through their deliveries. In theory, that eliminates the pressure on office-based physicians who don't want to leave their practices for a prolonged labor.
“In private practice, the incentives are that you want to be in the office,” Main said. “The pressures are around getting things done that don't take a lot of time.”
The CMQCC also has developed a toolkit of best practices, coming out next month, for hospitals looking to lower their C-section rates. It recommends hospitals encourage women to walk more during labor and employ less continuous fetal monitoring, which can raise false alarms.
But hospitals have different reasons behind their C-section rates, Main said, and the CMQCC can help providers figure out what's driving their numbers. Mostly, though, the group wants hospitals to know and understand what's going on at their facilities.
The Hospital Quality Institute also gave each hospital a preview of its data ahead of the wider release so facilities would have time to review and digest it, Morath said.
“When you don't have a chance to swim in the data … there's often less conviction around the data and what it means,” she said. “The first thing is awareness. The public reporting really galvanizes attention. So we welcome transparency.”