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Guide to Avoiding Unnecessary Cesarean Sections in New York State

April 21, 2010

Sidney Wolfe, M.D.
Public Citizen Health Research Group

Full report as a pdf
Statements from press conference

Introduction
Objectives
Methods
About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County

Variations in Cesareans, VBACs and Midwife Availability by County and by Hospital

Overall Cesarean Rates

The total number of cesarean deliveries in New York State in 2007 in the subset we analyzed was 85,244 (34.0 percent of the 250,780 deliveries for which the method of birth is known in the state that year[1].

Cesarean rates in New York vary more than 2.5-fold by county, ranging from a low of 16.6 percent for Cayuga County to a high of 43.1 percent for Westchester County (See Table 1). Cayuga has only one hospital performing deliveries and that is a Level 1 hospital without a neonatal intensive care unit (NICU); the rate therefore reflects practices in a single institution. Westchester, however, has eight hospitals, and the rates vary more than twofold among hospitals: from 25.2 percent to 52.7 percent. 

Even wider variations are seen among hospitals within the state and within each county (See Table 2).

The 10 hospitals with the lowest overall cesarean rates are:

  1. Auburn Memorial Hospital (16.6 percent)
  2. North Central Bronx Hospital (18.5 percent)
  3. Ellis Hospital - McClellan Division (18.7 percent)
  4. Seton Health System - St. Mary's Campus (20.4 percent)
  5. Samaritan Medical Center (20.6 percent)
  6. St. Barnabas Hospital (20.7 percent)
  7. Maimonides Medical Center (20.9 percent)
  8. Good Samaritan Hospital of Suffern (21.2 percent)
  9. Mary Imogene Bassett Hospital (22.3 percent)
  10. New York Downtown Hospital (22.3 percent)

The weighted average for all deliveries of the 10 hospitals with the lowest overall cesarean rates is 20.8 percent.

The 10 hospitals with the highest overall cesarean rates are:

  1. St. Anthony Community Hospital (53.3 percent)
  2. Lawrence Hospital Center (52.7 percent)
  3. Good Samaritan Hospital Medical Center (49.1 percent)
  4. St. Catherine of Siena Hospital (49.0 percent)
  5. Westchester Medical Center (47.5 percent)
  6. St. Charles Hospital (47.3 percent)
  7. Sound Shore Medical Center of Westchester (47.0 percent)
  8. Claxton-Hepburn Medical Center (46.8 percent)
  9. Plainview Hospital (46.7 percent)
  10. St. John’s Riverside Hospital - St. John’s Division (45.1 percent)

The weighted average for the 10 hospitals with the highest overall cesarean rates is 48.3 percent.

The 10 hospitals with the lowest overall cesarean rates include rural and urban hospitals and are located in the following counties: Cayuga, Bronx, Schenectady, Rensselaer, Jefferson, Kings (Brooklyn), Rockland, Otsego, and New York.

Similarly, the 10 hospitals with the highest rates include hospitals from rural and urban areas and are located in the following counties: Orange, Westchester, Suffolk, Saint Lawrence, and Nassau.

As indicated above, the average cesarean rate in the 10 hospitals with the highest rates is 48.3 percent. This rate is 2.3 times higher than the average for the 10 hospitals with the lowest rates (20.8 percent). It is interesting to note that the level of maternal-infant care (RPC, Levels 1, 2, or 3) for the 10 hospitals with the lowest cesarean rates (1, 2, 2, 1, 2, 3, RPC, 2, 1, and 2, respectively) was almost identical to that for the 10 hospitals with the highest rates (1, 2, 2, 2, 1, 2, 3, 1, 2, and 2, respectively).

If the average cesarean rate for New York hospitals in our subset were 20.8 percent ― that is, equal to the average cesarean rate for the 10 hospitals with the lowest rate ― only 52,162 women out of the 250,780 who delivered with method of birth was known would have delivered via cesarean section. This means there would have been 33,082 fewer cesareans that year than the 85,244 that actually were done. Thus, more than one-third of the cesarean sections in New York in 2007 may well have been unnecessary.

Primary Cesarean Rates

Primary cesareans — defined as cesarean delivery among women who have not had a previous cesarean — are considered a more accurate indicator of current practice than overall cesareans because the overall cesareans also reflect the now almost automatic repeat cesarean in women who have had one previously.

The primary cesarean rate is computed by dividing the number of women having a cesarean for the first time by the total number of deliveries by women who have never had a cesarean section. Women who have had prior cesareans or a VBAC are thus subtracted from the denominator in computing the rate.

In New York, VBACs and repeat cesarean sections may be undercounted. The primary cesarean rate may therefore have a larger denominator than is warranted, thus yielding a lower rate than the “true” one. Our numbers may therefore err on the conservative side, understating the primary cesarean rate.

Rates by County
The primary cesarean rate in New York is 21.1 percent and varies more than 3.5-fold by county. County-specific rates range from 7.5 percent (Cayuga County) to 26.4 percent (Westchester County); these two counties also represent the extremes for total cesareans in general (See Table 1).

Individual Hospital Rates
Even wider variations are seen between hospitals within the state (See Table 2).

The 10 hospitals with the lowest primary cesarean rates are:

  1. Auburn Memorial Hospital (9.9% percent)
  2. Phelps Memorial Hospital Assn (12.0 percent)
  3. St. Barnabas Hospital (12.2 percent)
  4. Brookhaven Memorial Hospital Medical Center Inc (12.2 percent)
  5. Samaritan Medical Center (12.3 percent)
  6. Ellis Hospital - McClellan Division (12.4 percent)
  7. North Central Bronx Hospital (12.4 percent)
  8. Seton Health System - St. Mary's Campus (13.2 percent)
  9. Catskill Regional Medical Center (13.4 percent)
  10. Good Samaritan Hospital of Suffern (13.8 percent)

The weighted average for the 10 hospitals with the lowest primary cesarean rates is 12.6 percent.

The 10 hospitals with the highest primary cesarean rates are:

  1. Lawrence Hospital Center (40.3 percent)
  2. Good Samaritan Hospital Medical Center (38.6 percent)
  3. St. Anthony Community Hospital (38.6 percent)
  4. St. Catherine of Siena Hospital (37.5 percent)
  5. Sound Shore Medical Center of Westchester (37.4 percent)
  6. Westchester Medical Center (35.5 percent)
  7. St. John’s Riverside Hospital - St. John’s Division (35.3 percent)
  8. New York Presbyterian - New York Weill Cornell Center (34.8 percent)
  9. Claxton-Hepburn Medical Center (34.6 percent)
  10. St. Charles Hospital (34.5 percent)

The weighted average for the 10 hospitals with the highest primary cesarean rates is 36.4 percent.

The 10 hospitals with the lowest primary cesarean rates include rural and urban hospitals in the following counties: Bronx, Cayuga, Westchester, Suffolk, Jefferson, Schenectady, Rensselaer, Sullivan, and Rockland.

Similarly, the 10 hospitals with the highest rates include hospitals from rural and urban areas in the following counties: Orange, Westchester, Suffolk, New York, and Saint Lawrence.

As indicated above, the average primary cesarean rate in the 10 hospitals with the highest rates is 36.4 percent. This rate is 2.9 times higher than the average for the 10 hospitals with the lowest rates (12.6 percent).

VBACs

Because of concerns about increased complications with some VBACs[2] and several high-profile cases in which women undergoing a VBAC ruptured their uterus, the American College of Obstetrics and Gynecology revised its guidelines in 1999 and in 2004 and adopted more restrictive conditions for the performance of VBAC. These guidelines require that institutions performing the procedure be “equipped to respond to emergencies with physicians immediately available to provide emergency care.”[3] Some have interpreted this to mean having an anesthesiologist available 24/7, while others have adopted a time span (15, 20, or 30 minutes) within which staff must be available. Hospitals that do not meet this standard have stopped doing VBACs: nationally, that means that 28 percent of hospitals that have labor and delivery wards did not allow VBACs in 2009. And an additional 21 percent of hospitals have “de facto” bans because, even when they have no official policy against the procedure, they have no obstetricians who will perform them.[4] Since 1996, approximately one-third of hospitals and one-half of physicians no longer offer a trial of labor to women with a prior cesarean.[5] 

The VBAC rate in New York is 9.3 percent, higher than that for the country as a whole, which is 8.0 percent. As expected, within New York this rate varies by hospital, county, level of perinatal care, and size of hospital. Nineteen of the 143 hospitals we examined, accounting for 13.3 percent of the total, did not report performing VBACs in 2007. Among those that performed this type of delivery, the VBAC rate varied more than 900-fold, from .03 percent to 28.13 percent.

Rates by County
County-specific VBAC rates among those counties with at least one hospital performing VBACs vary more than 19-fold, from 1.1 percent in Oswego County to 21.1 percent in Rensselear (See Table 2).

The 19 hospitals with VBAC rates of 0.0 percent are:

  • Adirondack Medical Center - Saranac Lake Site
  • Aurelia Osborn Fox Memorial Hospital
  • Bon Secours Community Hospital
  • Chenango Memorial Hospital, Inc.
  • Cortland Regional Medical Center, Inc.
  • Eastern Niagara Hospital - Lockport Division
  • Eastern Niagara Hospital - Newfane Division
  • Edward John Noble Hospital of Gouverneur
  • Glens Falls Hospital
  • Lakeside Memorial Hospital
  • Medina Memorial Health Care System
  • Memorial Hospital of William F. and Gertrude F. Jones
  • Nathan Littauer Hospital
  • Richmond University Medical Center
  • Rome Memorial Hospital, Inc.
  • Schuyler Hospital
  • Sound Shore Medical Center of Westchester
  • Westfield Memorial Hospital, Inc.
  • White Plains Hospital Center

The 10 hospitals with the highest VBAC rates are:

  1. Seton Health System-St. Mary's Campus (34.4 percent)
  2. North Central Bronx Hospital (30.9 percent)
  3. Maimonides Medical Center (30.0 percent)
  4. Harlem Hospital Center (28.1 percent)
  5. Good Samaritan Hospital of Suffern (23.9 percent)
  6. Northern Dutchess Hospital (22.9 percent)
  7. Jacobi Medical Center (22.3 percent)
  8. Samaritan Medical Center (22.2 percent)
  9. Staten Island University Hospital - North (21.9 percent)
  10. NYU Hospitals Center (21.4 percent)

The average for the 10 hospitals with the highest VBAC rates is 25.4 percent. This average is 2.7 times higher than the state average VBAC rate of 9.3 percent.

The 10 hospitals with the highest VBAC rates are located in New York County, Bronx, Kings (Brooklyn), as well as hospitals in Dutchess, Jefferson and Rensselear counties. Other counties with at least one hospital performing VBACs on at least 15 percent of women with a previous cesarean section include Monroe, Rockland, and Wayne counties.

Midwife Deliveries in Hospitals

While midwives attend 7.0 percent of all births in the United States, they attended 9.6 percent of all deliveries in New York State in 2007.

As is the case with overall and primary cesarean rates and VBAC rates, there is enormous variation among counties in New York in the availability of midwife deliveries. The rates ranged from 0.0 percent in several counties (no hospitals providing midwife deliveries) to 58.2 percent in Warren County (See Table 1).

Even wider variations in midwife deliveries are seen among hospitals within the state (See Table 2).

In New York, 44 hospitals do not provide midwife-attended births; these are:

  • Albany Medical Center Hospital
  • Alice Hyde Medical Center
  • Bon Secours Community Hospital
  • Brookhaven Memorial Hospital Medical Center, Inc.
  • Brooks Memorial Hospital
  • Chenango Memorial Hospital, Inc.
  • Claxton - Hepburn Medical Center
  • Corning Hospital
  • Eastern Niagara Hospital - Newfane Division
  • Edward John Noble Hospital of Gouverneur
  • F. F. Thompson Hospital
  • Faxton - St. Luke’s Healthcare St. Luke’s Division
  • Flushing Hospital Medical Center
  • Geneva General Hospital
  • Good Samaritan Hospital Medical Center
  • Lawrence Hospital Center
  • Lenox Hill Hospital
  • Lewis County General Hospital
  • Lincoln Medical & Mental Health Center
  • Long Island Jewish Medical Center
  • Massena Memorial Hospital
  • Mount St. Mary’s Hospital and Health Center
  • New York Downtown Hospital
  • New York Hospital Medical Center of Queens
  • New York Presbyterian - New York Weill Cornell Center
  • New York Presbyterian Hospital - Columbia Presbyterian Center
  • Niagara Falls Memorial Medical Center
  • Nicholas H. Noyes Memorial Hospital
  • Oneida Healthcare Center
  • Peconic Bay Medical Center
  • Queens Hospital Center
  • Richmond University Medical Center
  • St. John’s Riverside Hospital - St. John’s Division
  • Sound Shore Medical Center of Westchester
  • Southampton Hospital
  • Southside Hospital
  • St. Anthony Community Hospital
  • St. James Mercy Hospital
  • Strong Memorial Hospital
  • University Hospital of Brooklyn
  • Westchester Medical Center
  • Westfield Memorial Hospital, Inc.
  • Woman's Christian Association
  • Wyckoff Heights Medical Center

The 10 hospitals with the highest percentage of midwife deliveries are:

  1. North Central Bronx Hospital (79.8 percent)
  2. Mary Imogene Bassett Hospital (70.1 percent )
  3. Woodhull Medical & Mental Health Center (69.5 percent)
  4. Glens Falls Hospital (58.2 percent)
  5. Rome Memorial Hospital, Inc. (55.7 percent)
  6. Seton Health System-St. Mary's Campus (52.7 percent)
  7. Community-General Hospital of Greater Syracuse (51.3 percent)
  8. Phelps Memorial Hospital Association (50.2 percent)
  9. Schuyler Hospital (47.1 percent)
  10. Catskill Regional Medical Center (44.8 percent)

The average for the 10 hospitals with the highest percentage of midwife deliveries is 62.0 percent. This rate is 6.5 times higher than the state average percentage of hospital deliveries done by midwives (9.6 percent). It should be noted that midwife-assisted deliveries are widely available in both rural and urban settings.

In addition to the above 10 hospitals, representing Bronx, Otsego, Kings (Brooklyn), Warren, Oneida, Rensselaer, Onondaga, Westchester, Schuyler, and Sullivan counties, at least one hospital in the following counties had at least 25 percent of births attended by midwives: Putnam, Dutchess, Kings (Brooklyn), Tompkins, Clinton, New York, Chemung, Genesse, Cattaraugus, Jefferson, Rockland, Franklin, Rensselaer, Sullivan, Schuyler, Westchester, Onondaga, Rensselaer, Oneida, Warren, Kings (Brooklyn), Otsego, and Bronx. 



[1] This number differs slightly from the CDC figure cited above, because we looked at a subset of the hospitals in New York State. See Methods for more details.

[2] McMahon, Michael J., Edwin R. Luther, Watson A. Bowes, and Andrew F. Olshan. "Comparison of a Trial of Labor with an Elective Second Cesarean Section." New England Journal of Medicine 335.10 (1996): 689-95. Web. <http://content.nejm.org/cgi/content/full/335/10/689>.

[3] Porter, T. F., and Carolyn M. Zelop. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Rep. Vol. 54. 2004. Print.

[4] Pamela Paul, The Trouble with Repeat Cesareans, Time. February 19, 2009. <http://www.time.com/time/printout/0,8816,1880665.00.html>

[5] National Institutes of Health Consensus Development Conference: Vaginal Birth After Cesarean. 2010. Print.

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