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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

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

Healthy Outliers: Two New York Hospitals That Have Bucked the Trend

Given the fact that the rate of cesarean sections has risen significantly and the rate of VBACs has fallen in New York and nationally, we have focused on two hospitals that shed light on effective intervention strategies. Both have managed to achieve and maintain low rates of surgical delivery. And because they are in New York City and serve a varied population in the Bronx and Brooklyn, they are excellent examples of hospitals that have overcome the prevailing surgical trend to achieve favorable birth outcomes while serving diverse populations.

North Central Bronx Hospital

North Central Bronx Hospital is a 213-bed facility that is part of the Health and Hospitals Corporation network of care. It the sole public provider of health care services in the North Bronx. It has an annual average of 35,400 inpatient discharges and 558,500 outpatient visits. It is a public institution that serves the medically underserved, the uninsured, and Medicaid/Medicare recipients. Medicaid pays for 96.3 percent of all births. The hospital is an academic affiliate of the Albert Einstein College of Medicine (AECOM), with many of its physicians appointed to the AECOM faculty. It is a Level 2 hospital in the state’s perinatal system.

In 2007, North Central Bronx Hospital handled 1,751 births. Of these, 18.5 percent (324) were cesareans, almost half of the average rate for Level 2 hospitals as a whole. The hospital has the lowest cesarean section rate in New York State for a hospital of its size and level of complexity. The hospital also has an unusually high rate of VBACs: 34.1 percent, more than three times that for the state as a whole.

What distinguishes North Central Bronx Hospital from others in New York State is the high rate of births attended by midwives: 79.8 percent, compared to 9.6 percent for the state as a whole. This has created a unique culture of birthing that favors a supportive environment for women and instills a sense of self-efficacy, allowing them to opt for a vaginal birth when they have had a prior cesarean. The fact that this is taking place in a hospital that serves what could otherwise be considered ”high-risk” mothers suggests that similar indicators could be achieved elsewhere.

Maimonides Medical Center

Maimonides is a Regional Perinatal Center (RPC) located in Brooklyn. The hospital is a 705-bed community hospital with a centennial history. It is among the largest teaching hospitals in the nation, training more than 450 medical and surgical residents annually. It delivers more than 7,000 babies per year, the largest number for a single hospital in New York State. Medicaid pays for 68.7 percent of all births at Maimonides. 

Despite its RPC designation and full complement of high-technology ob/gyn services for high-risk women, the hospital has a birthing center encompassing an 11-room labor and delivery suite. It also has a full staff of hospital-based midwives, private practice midwives with admitting privileges as well as a team of physicians’ assistants and a corps of volunteer doulas. In 2007, 13.0 percent of births were attended by midwives.

Maimonides has been recognized for its excellence in patient outcomes and its significantly lower risk-adjusted mortality and complication rates. In the area of obstetrics, it has one of the lowest cesarean section rates in the state and a significantly lower rate than any of the other New York RPCs: 20.9 percent. It also has a VBAC rate more than three times higher than the average for the state: 31.1 percent.

Maimonides Chairman of Obstetrics and Gynecology, Dr. Howard Minkoff, has stated that, nationally, the VBAC rate needs to be increased from the current rate of 9.6 percent (2006 data) to at least halfway to the peak level of 28.1 percent in 1996. He further states that attempted vaginal birth after a previous cesarean should be offered to all women without clear contraindications. This assumes that if, after a trial of labor, it is necessary to do a cesarean section, this can be immediately implemented by an obstetrician and the hospital staff.[1] The VBAC rate at Maimonides of 31.1 percent demonstrates that Dr. Minkoff and his colleagues practice what they preach.

Part of the hospital’s low cesarean rate is attributed to the cultural and religious beliefs of the population it serves. Located in the heart of Borough Park, Maimonides serves the Hasidic and Orthodox communities, but this population does not account for a very large proportion of births at Maimonides. Women from these communities value large families – the average Hasidic family in the U.S. has 7.9 children – and do not want to limit their future childbearing options by having a cesarean section.

[1] Communication with Dr. Minkoff, April 1, 2010.