April 21, 2010

Cesarean Sections Are Overused in New York, Giving the State One of Highest C-Section Rates in the Country

Public Citizen Releases a Guide to Avoiding Unnecessary Cesareans in New York; New Online Report Provides Statistics by County and Hospital

WASHINGTON, D.C. – Nearly a third of cesarean sections in New York state may be performed unnecessarily, and rates of the procedure there are among the highest of states in the country, according to a Public Citizen report released today.

Within New York state, rates of C-sections performed vary widely. Public Citizen’s report and an accompanying Web site break down the data by county and hospital, so patients can see how high C-section rates are for their local hospital in comparison to other local hospitals.

“There is a growing epidemic of C-sections in the United States, where the 2007 national rate of 31.8 percent was the highest it has ever been,” said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. “We estimate that one-third of cesareans are unnecessary, nationally and in New York. These therefore represent unnecessary acts of violence against women. Unnecessary cesareans mean that the health of mothers and their babies are being needlessly jeopardized because mothers go under the knife instead of delivering vaginally.”

The estimate that one-third of New York C-sections are unnecessary is based on the fact that the average C-section rate at the 10 New York hospitals with the lowest rate was 20.8 percent, more than one-third lower than the average New York rate for all hospitals. 

The New York state hospital with the highest percentage of total C-sections was St. Anthony Community Hospital (Orange County) with 53.5 percent of deliveries by C-section. Auburn Memorial Hospital in Auburn had the lowest percentage of C-sections, with a rate of 16.6 percent.

Among urban hospitals, the lowest rates were at North Central Bronx Hospital, with only 18.5 percent of deliveries done by C-section; St. Barnabas Hospital (Bronx), with 20.7 percent; Maimonides Medical Center (Brooklyn), with 20.9 percent; and New York Downtown Hospital, with 22.3 percent. In contrast, other urban hospitals had very high C-section rates, such as University Hospital of Brooklyn (Brooklyn), with 40.2 percent; NewYork-Presbyterian at Weill Cornell Medical Center, with 39.2 percent; Lenox Hill Hospital, with 40.1 percent; and Long Island Jewish Medical Center, with 40.3 percent. Six of the eight hospitals in Westchester County also had rates exceeding 39.5 percent.

Public Citizen researchers created a database of 2007 data from hospitals in New York, one of only two states that provide details about all obstetric procedures at the facility level, then analyzed it. The numbers came from the state’s 143 hospitals that handle more than 30 births a year. New York has a higher C-section rate (33.7 percent overall, 34 percent in the subset we analyzed) than the country as a whole, with only eight states having higher rates. 

Public Citizen’s analysis provides the rates of overall and primary C-section (those performed on women who have not had a C-section previously), as well as rates of vaginal births after cesareans (VBACs), by county and hospital. C-section rates in New York vary more than 2.5-fold by county, ranging from a low of 16.6 percent in Cayuga County to a high of 43.1 percent in Westchester County. (The full results can be viewed at www.citizen.org/hrg1906.)

Contrary to expectation, the largest hospitals did not have the highest C-section rates, nor was there a consistent relationship between the size of a hospital and its rate of performing C-sections. Rural hospitals had slightly higher overall rates of C-sections than urban hospitals, perhaps because they lack the resources to provide emergency care to handle VBACs.

After several high-profile cases in which women who have had previous C-sections opted to deliver vaginally – and then ruptured their uterus – the American College of Obstetrics and Gynecology revised its guidelines for institutions performing vaginal births after C-sections.

The guidelines now state that hospitals performing VBACs must be “equipped to respond to emergencies with physicians immediately available to provide emergency care.” As such, 28 percent of U.S. hospitals did not allow VBACs in 2009, and an additional 21 percent had “de facto” bans on the procedure because their obstetricians would not perform them.

Nationally, the steep rise in C-section – from 10.4 percent of all deliveries in 1975 to 31.8 percent of all deliveries in 2007 – is a growing concern for those committed to improving the health of mothers and infants. C-sections are being performed now more than ever.

“The model of obstetrical care in this country is all wrong,” said Dr. Jacques Moritz, an obstetrician at St. Luke’s-Roosevelt, Roosevelt Division. “The model of an overtrained obstetrician attending to a normal birth is all wrong. The proper model is for all low-risk mothers to be managed by a certified midwife with a midwife-friendly obstetrician as back-up. Midwives offer a high-touch versus high-tech approach to delivery.”

Added Susannah Donahue-Negbaur, a licensed midwife at the same hospital, “Research shows that low-risk women who use midwives are more likely to have a safe and healthy birth for themselves and their babies, and are less likely to undergo an induction of labor, cesarean or episiotomy than low-risk women who use doctors. The best maternity care is a partnership between doctors, midwives and families. If you are pregnant, healthy and low-risk, you are in very good hands with a midwife.”

Increasing the number of VBACs is another crucial way to reduce the number of unnecessary C-sections, according to Dr. Howard Minkoff, chief of obstetrics and gynecology at Brooklyn’s Maimonides Medical Center, a hospital with a VBAC rate of 30.0 percent, 3.2 times higher than the state average.

“Perhaps the most important step in turning cesarean section rates around is embracing a philosophy that defines a successful hospital stay as the discharge of a healthy mom who delivered a healthy baby vaginally,” Minkoff said. “No one would argue that the mode of delivery should trump health considerations of the mother or child, but there are no data demonstrating that ever better health outcomes have been achieved by ever higher operative delivery rates.”

To reduce or stabilize C-section rates, Public Citizen recommends that health departments and hospitals require all hospitals to offer the alternative of delivery by a licensed midwife, adopt peer review in all aspects of maternal and fetal care, require all ob/gyns to get a second opinion before deciding on a primary C-section, standardize care right before and after birth, and eliminate financial incentives for performing C-sections (physicians are paid more for performing C-sections, even though they may take less time to perform than vaginal deliveries).

Mothers who want to avoid an unnecessary C-section should talk to their doctor or midwife early about their preferences, use data in the report to find out the rates of C-sections and VBACs in the hospitals they are considering using for their pregnancies, consider using a licensed midwife and use a doula (a woman experienced in childbirth who provides continuous labor support) in conjunction with their doctor.

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Public Citizen is a national, nonprofit consumer advocacy organization based in Washington, D.C. For more information, please visit www.citizen.org.