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

About New York

The fact that few states routinely publish statistics on cesarean sections performed in their hospitals limits national studies based on routinely collected data. Indeed, New York is one of only two states that provide intervention rates for all obstetric procedures at the facility level.[1]

We have chosen to look at the data for New York State to examine how cesarean sections vary by different factors associated with health care delivery. While New York’s transparency with respect to maternity data makes it an outlier in terms of the rest of the nation, the state nevertheless serves as a model for other states. Moreover, in addition to maintaining updated hospital-specific data that are easily retrievable, New York offers the following advantages:

1. New York has over 200 hospitals, most of which provide maternity services. This sample is large enough to provide information on rates by level of care and size of hospital.
2. The state has a large population, with ethnic and racial diversity, urban and rural residents, and a full range of hospital types, from small facilities with a limited catchment area to major medical centers serving a statewide, national, and even international population. It can therefore reflect conditions for the nation as a whole.
3. The state is a leader in medical education and has a disproportionate share of medical schools and graduate training programs. For this reason, New York can be considered a bellwether in the use of technology and the adoption and diffusion of medical practices. 

New York has a regionalized system of perinatal care which classifies maternity services into four levels and stratifies risks accordingly.[2] Each region is headed by a Regional Perinatal Center (RPC) that provides the full range of services required for high-risk women and newborns. Other hospitals in each area are classified as follows:

• Level 1 hospitals provide care to normal and low-risk pregnant women and newborns, and they do not operate neonatal intensive care units (NICU);
• Level 2 hospitals provide care to women and newborns at moderate risk and do operate NICUs;
• Level 3 hospitals care for patients requiring increasingly complex care and operate NICUs.[3]

The perinatal hierarchy of care is predicated on hospitals being explicitly differentiated by level of expertise and technology. This facilitates matching medical needs and resources by referring patients with potential maternal and fetal problems to facilities in which they can get appropriate care.

New York State has a higher cesarean rate than the country as a whole: 33.7 percent vs. 31.8 percent. According to data from 2007, the rate in New York is exceeded by only nine states.[4] At the same time, New York has a higher rate of VBACs: 9.3 percent, compared to 8.0 percent for the country as a whole.