The likelihood a woman will receive a cesarean section or an episiotomy, an incision made to widen the birth canal, depends greatly on the hospital where she gives birth, according to the Leapfrog Group's most recent Maternity Care Report.
The analysis, released each year since 2014 in partnership with Castlight Health, found the rate of episiotomies and C-sections varied significantly between hospitals in the same city and region.
For example, rates of episiotomies in Los Angeles range from 0.5% to as high as 47.3%, depending on the hospital. In Chicago, one hospital had an episiotomy rate of 3.4% while another 9.1 miles away had an episiotomy rate of 20.2%. A similar trend holds true in Dallas where the episiotomy rate was 2.8% at one hospital and 18.4% at another 9.7 miles away.
The Leapfrog Group, which relies on a panel of quality experts, recommends a hospital have an episiotomy rate of 5% or lower.
On the bright side, Leapfrog found that the overall rate of episiotomies across all hospitals declined from 9.6% in 2016 to 7.8% in 2017.
"The episiotomy rate did go down significantly. We don't see improvements quite that dramatic every year," said Leah Binder, president and CEO of Leapfrog. "There are clearly efforts being made by many hospitals and clinicians across the country to decrease the rate and that is good — they are clearly on the right track."
The Leapfrog Group conducted its analysis by using data from its 2017 Hospital Survey, which nearly 2,000 hospitals voluntarily submitted.
As for C-sections performed on first-time mothers with a single baby at term and positioned head-down, it depended on the region. Hospitals in the Pacific Northwest, Mountain states and the Southwest were less likely to perform these C-sections than hospitals in the Midwest and the Southeast.
However, even in regions with low C-section rates, some hospitals still performed poorly. For instance, C-section rates at Seattle hospitals varied from 18.7% to 39%.
"When you see variation like this there clearly hasn't been a national or regional effort to bring the rates down," Binder said. "For whatever reason, some hospitals haven't made it a priority."
Binder called on hospitals, state hospital associations, not-for-profits and the federal government to invest in ways to reduce the high C-section rate. She pointed to the nationwide campaign to decrease the elective delivery rate in recent years as proof that such efforts work. The elective delivery rate has dropped from 17% in 2010 to 1.6% in 2017.
Leapfrog recommends a C-section rate of 23.9% or lower for first-time mothers with a single baby at term and positioned head-down. Women with these pregnancies are considered less likely to need the procedure. The complications associated with these kinds of C-sections include infections for mothers, longer recovery time and difficulty with future pregnancies.
Additionally, Leapfrog found worse performance from 2016 to 2017 in the overall C-section delivery rate. Only 40% of hospitals met Leapfrog's 23.9% standard C-section rate in 2017 compared with 2016 when 44.7% of hospitals met Leapfrog's standard.
"This lack of progress is highly alarming and great cause for concern," the report said.
The Leapfrog Group's findings correlate with previous research on maternity care in the U.S. A 2013 study found C-section delivery rates vary tenfold between hospitals, while a 2015 study found wide variation in episiotomy rates between hospitals.
Research on both procedures demonstrate that it's usually a hospital's practice patterns that determine its rates, not the clinical condition of the mother and baby.
