"It's about the culture of the medical staff, and the expectations among colleagues of when these procedures are necessary," Binder said. "And when there is a strong effort to reduce them, they get reduced."
According to the American College of Obstetricians and Gynecologists, most pregnancies in the U.S. are low-risk, and in these cases, C-sections appear to actually pose greater risk of maternal morbidity and mortality than vaginal delivery. And C-sections are also associated with greater risk of infection, longer hospital stays and hospital readmissions.
The report also broke out states that had the worst C-section rates overall. Kentucky hospitals that were surveyed reported average rates of 29.4% of these kind of C-sections. Louisiana, Mississippi and New York fell right behind as having high C-section rates. Meanwhile, Wyoming, Utah and Colorado hospitals reported rates below 19%.
"Variation is the story when it comes to C-sections in this country: it's all over the map, and there's no predicting which kind of hospital is going to have the highest rate," Binder said. "Physicians will typically perform in line with what others in their circle of influence do. And that's why it's important for physicians to recognize the influence of culture, and to question whether that is the right thing for their patients."
But there are bright spots and indication that hospital practices can change: the majority of hospitals are reducing episiotomies, which is when a clinician makes an incision below the vaginal opening during birth. While this was once a mainstream practice in an effort to prevent tearing, research shows risks outweight the benefits for most births, with an increased risk of loss of bladder or bowel control, and pelvic floor defects. ACOG recommends against the practice for most births.
The average rate of episiotomies has decreased by almost half since 2015, and in 2020 the majority of hospitals reported having conducted the procedure for 5.2% or less of deliveries, almost meeting the Leapfrog goal of 5%.
"I really do commend the healthcare community, physicians and nurse midwives, for being able to bring this rate down; that is not easy to do, and we don't see it every day," Binder said.
The group also found sustained progress in reducing early elective deliveries, with the average rate falling from 17% in 2010 to 1.6% in 2020. These deliveries can be medical inductions or C-sections that occur before 39 weeks gestation without a medical reason. Studies show that these early elective deliveries can increase long-term health risks for infants and increased NICU admissions.
"That's an incredible success story of healthcare in this country: it was never a good idea to do early elective deliveries, and galvanized by transparency, there's been incredibly effective physician and hospital leaders," Binder said. "And I think that what it tells us is it's possible to actually improve maternity care in this country."
The hospitals who voluntarily reported represent about 75% of hospital beds in the U.S. Providers that declined to respond and did not provide data include hospitals in the Advocate Health system in Illinois, and the vast majority of hospitals in Minnesota and Wisconsin, among others.