Why Boston-Area Hospitals Have A Big Range In C-Section Rates

Though only performed on women, Cesarean sections — the incision in a woman’s abdomen and uterus through which doctors deliver a baby — have become the most common surgery in the U.S.

Many health care experts grimace at this news. Research shows a C-section can have negative consequences for both the mom and the baby. And though childbirth experts have been pushing to reduce C-sections, their sense of urgency has not spread to many doctors or moms, who say C-sections are an important option in the process of delivering a healthy baby.

So are C-sections really that bad? Lots of women have one. It’s generally considered low-risk surgery. You can barely see the scars these days. And there’s some dispute about whether they really cost a lot more than a normal vaginal delivery.

So if you’re wondering why some people get worked up about rising C-section rates, listen to Dr. Catherine Spong, with the National Institute of Child Health and Human Development. She says birth is a natural process that prepares a baby to enter the world.

“If you have a Cesarean delivery without any labor, without going through any of those processes, sometimes [babies] have problems with that transition because they haven’t undergone all of those physiologic changes,” Spong says.

There’s a growing body of evidence that children born by C-section are more at risk for asthma, type 1 diabetes and obesity. And there are risks for the mom, so preventing first-time births by C-section is particularly important.

“Once you’ve had a Cesarean and you have an incision in the uterus, that incision could open, called uterine rupture,” Spong says. “That can be catastrophic for both mom and that subsequent baby.”

The odds of that rupture and other bleeding problems are not high, but go up with each birth.

The federal government had hoped to cap Cesarean sections at 15 percent of all births by 2010, but the country blew right past number. In Massachusetts, 23 percent of first-time moms have C-sections. But within the state there’s a big range.

In the Boston area, Cambridge Hospital has the lowest rate of C-sections, at 15 percent, according to data collected by the state Department of Public Health. Tufts Medical Center has the highest rate, with 30 percent, but that’s only slightly more than other prestigious teaching hospitals, such as Brigham and Women’s and Beth Israel Deaconess.

Nurse manager Jessica Buinicki, left, and Dr. Kate Harney sit in the birth center at Cambridge Hospital. (Martha Bebinger/WBUR)

Nurse manager Jessica Buinicki, left, and Dr. Kate Harney sit in the birth center at Cambridge Hospital. (Martha Bebinger/WBUR)

The gap in rates may have something to do with the culture of these hospitals.

At Cambridge, Tufts Hospitals

The culture of childbirth at Cambridge Hospital begins in a Victorian house, across a driveway from the main hospital lobby. It’s the Cambridge Birth Center. Both the hospital and birth center are part of Cambridge Health Alliance.

The center is as close to a homebirth as you can get without staying home. Dr. Kate Harney, the hospital’s chief of obstetrics and gynecology, walks up a winding staircase into a room with big windows, painted a soft blue. She sits down on a four-poster bed covered with a diamond-pattern quilt.

The room “has all the emergency equipment,” Harney says, but it’s “nicely hidden away.”

Only about 10 percent of pregnant women who come to Cambridge Hospital give birth in this house. Most women choose a more traditional experience in the main hospital. But Harney says the natural birth focus of the center sets the tone for all hospital deliveries.

“A lot of patients are initially drawn to us here because of our birth center,” Harney says, “so that affects how we care for patients in the hospital. We all have to be philosophically and medically ready to take care of women who have this approach to childbirth.”

This approach includes:

  • An obstetrician, or OB, assigned to the hospital’s labor and delivery unit 24 hours a day. OBs at Cambridge Hospital don’t race back and forth between patients in the office and patients in labor, a pressure doctors in many hospitals with high C-section rates face.
  • Using family doctors and midwives, who are not trained to do C-sections, to perform almost half the births at Cambridge Hospital.
  • Holding off on induced labor until two weeks after a woman’s due date. Earlier inductions that don’t progress to full labor are tied to C-sections.
  • Using doulas, or birth coaches, to assist in about a quarter of all deliveries.

Harney says doulas are one way the hospital helps women who aren’t ready for a long labor to get through it.

“Women expect to come in and deliver in a few hours,” she says, “and what’s realistic is that most labors are 12-24 hours. Patients always think it’s going to be faster than it is.”

There’s a culture of avoiding C-sections at Cambridge Hospital that goes beyond the medical benefits. Jessey Buinicki, the hospital’s nurse manager for maternity services, has been encouraging women to deliver vaginally for 20 years and has three daughters who are moms.

“It’s been very empowering, it’s changed them from girls to women almost,” Buinicki says. “In our society we don’t look at that, we’re all clinical and everything, but still the basic idea that you’re giving birth to your child is huge and should have more weight than maybe it does.”

Nurse Linda McAvoy, left, and Dr. Sabrina Craigo in the NICU at Tufts Medical Center's Floating Hospital for Children. (Martha Bebinger/WBUR)

Nurse Linda McAvoy, left, and Dr. Sabrina Craigo in the NICU at Tufts Medical Center’s Floating Hospital for Children. (Martha Bebinger/WBUR)

Cambridge Hospital does not have a Neonatal Intensive Care Unit, or NICU. So moms with high-risk deliveries who go to Cambridge would likely be sent to another teaching hospital in Boston, such as Tufts Medical Center, which does have a NICU.

Dr. Sabrina Craigo, the director of maternal fetal medicine at Tufts, says the NICU helps explain why its C-section rate is 30 percent.

“We do 1,100 to 1,200 deliveries a year and at least half of those are high risk,” Craigo says. “But those that are complicated, there’s just a higher risk of having a C-section.”

Craigo sits in the hospital’s NICU amid tiny babies nestled in heated incubators, hooked up to tubes and monitors. Fifty-five percent of babies here, on average, were delivered via a C-section. Tufts, unlike Cambridge, does not use midwives. The hospital does make every effort, says Craigo, to avoid a C-section and she agrees that C-section rates are an important quality marker. But Craigo says comparing rates for smaller hospitals that are not equipped to care for premature babies and high-risk pregnancies may make more sense.

“Certainly the very high C-section rate in a community setting should raise your concerns,” Craigo says, offering advice for pregnant women. “The 24 weekers [very early babies] are not being delivered in any of the community hospitals, so I think that is a distinction,” between the community hospitals and Tufts or other teaching hospitals.

C-Section Research

But when researchers filter out the high-risk babies and just look at moms whose babies were in position for a normal vaginal delivery, some hospitals are still doing C-sections at almost three times the rate of other hospitals in Massachusetts. Why? No one seems to know.

Dr. Neel Shah, an OB at Beth Israel Deaconess Medical Center, says time pressures in some hospitals may lead to more C-sections.

“The decision that we’re talking about is the difference between something that takes a lot of time and effort [a vaginal birth] and something that takes a lot less time and effort [a C-section],” he says.

Shah heads a new project that’s mapping the decisions leading up to a C-section. It’s under the guidance of Dr. Atul Gawande, whose surgical checklists have reduced complications and deaths around the world.

Shah says research shows that a physician’s fear of a lawsuit does not explain the difference in C-section rates. Could it be that there are more older mothers, or more women having twins, or more women who are obese, or more women with a disease that complicates their pregnancy?

These factors may help explain why women are having C-sections, but they do not explain why some doctors do more C-sections than others. Shah is reviewing the theory that C-sections have risen with the use of fetal health monitors.

He told a roomful of physicians at Beth Israel Deaconess last fall that something is wrong with childbirth practices in the U.S. because, “You guys are on the only continent on the planet with an increasing maternal mortality rate.”

(Courtesy Neel Shah)

(Courtesy Neel Shah)

Shah says there’s no proof that C-sections are the cause of rising death rates for moms during childbirth. There could be many factors. But researchers say the risk of ruptures and bleeding that increases with every additional C-section is under scrutiny. And hospitals are under increasing pressure to reduce C-sections. Public and private insurance plans are beginning to tie penalties or bonus payments to C-section rates.

There are many cases in which C-sections are the only safe way to deliver a baby. But if you are young and healthy and the hospital you plan to use does more C-sections than others in your area, you might talk to your doctor about why.

Check out our interactive tool to see how Cesarean section rates and four other childbirth quality measures differ at every hospital that performs deliveries in Massachusetts.

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  • Jenifer Holloman

    “Public and private insurance plans are beginning to tie penalties or bonus payments to C-section rates.”

    GGGeeeereat, now we’re tied to penalties and bonuses. super.

  • Laurie Ann Friedman

    As one of the founding midwives of the Cambridge Birth Center and Multicultural Doula and Childbirth education and CenteringPregnancy in the community health centers I think it’s kind of bizarre to see Dr. Harney and the nurse manager sitting on the birth center bed. Where are the midwives and the birth center families? Midwifery lead care in pregnancy focuses on empowering women and families to understand and optimize pregnancy, birth and breast feeding as physiological processes that do not require intervention in most situations. This is rarely the type of care a women gets at even the best of hospitals. Both a medical model of birth as a disaster waiting to occur and cultural expectations of control and perfection and our terrible family leave policies (compared with all those countries with better maternal infant outcomes than the US) all contribute to the mess of expectations and outcomes we have in MA. I disagree that quality is impossible to measure, but our current method of caring for pregnant women and newborns is driven by many financial, organizational and social factors that trump the evidence we have about quality care.

  • Abi

    I gave birth in August via c-section, a procedure that likely saved my daughter from brain damage or other complications. I was a patient at Brigham and Women’s, where, despite the “high” c-section rate, I had many of the hallmarks of great care
    identified in the article, including care from a certified nurse midwife from my first prenatal visit up until I was wheeled into the operating room. But none of that could convince my body to go into labor, or disentangle my daughter from the umbilical cord that was wrapped around her neck three times.

    I found the story’s implications that women who have c-sections aren’t tough or “womanly” enough to be both bizarre and insulting. The next time you’re reporting on a complex medical phenomenon, perhaps rather than scratching your head over some spreadsheets you could actually talk to some patients about the series of
    decisions that led to them undergoing these procedures.

    • Martha Bebinger

      Hi Abi – I’d like to hear more about why you find the story insulting. I too had an emergency C-section. I’m pretty sure I would not be here today if the procedure was not available. I’m also very happy that you got the care you needed.

      There is no question that we need this option. The question is, do we perform too many and perhaps, why?

      • Abi

        Martha – Thanks for your reply. What I found insulting were the implication that vaginal birth made one expert’s daughter’s “more womanly,” (implying that those of us who haven’t gone through that are less than), or the implication that women wind up having c-sections because they expect a fast and easy labor. You mention that many c-sections are medically necessary almost as an afterthought, leaving the overall impression, as I heard it, that most women who wind up getting c-sections were somehow just wimping out. Focusing more on what makes a c-section medically necessary could have helped to balance that out.

        • Martha Bebinger

          Ah Abi – I get it. Good points. Thanks for the reply.

  • Jazmin Mostafa

    I had a great experience at Cambridge Hospital, I did have to have a C-section because my twins were both head up, although I went into labor naturally. Great experience, my kids are happy and healthy and were born at a decent weight, thanks to my pre-natal care and the delivering doctor who couldn’t have made me feel more comfortable and important. They did tell me that I’d have to go to Tufts if I went into labor or the babies needed to come out before 36 weeks in order to have access to the NICU, should it be needed and it most likely would have been.

    I agree with what I believe the article implies which is that, Tufts probably has a higher rate of C-sections because they have the NICU and automatically get patients with high-risk pregnancies who seek out Tufts or who are given to Tufts by hospitals like Cambridge Hospital who don’t have NICU. And perhaps mothers with healthy pregnancies who want a C-section seek out Tufts because they clearly have more practice with it? So I also agree that looking at hospitals with higher percentages doesn’t necessarily reflect their stance on voluntary/unnecessary c-sections, but certainly does reflect on hospitals who have low percentages, for those mothers who are looking for a birth experience where a c-section won’t be imposed on them.

  • Lisa Murakami

    The authors of the study cited above commit the same error as do many similar studies of C-section rates; they focus on process as opposed to outcome. We shouldn’t be looking for an ideal average C-section rate. We should be looking for the C-section rate that produces the best outcomes. How does the perinatal mortality rate compare between hospitals with low C-section rates and high C-section rates? The authors don’t know because they never looked. Indeed, the underlying (and totally unjustified) assumption that permeates the entire study is that there is no appreciable difference in mortality rates between various hospitals and that, therefore, we can focus on difference in C-section rates.

    But perinatal mortality rates do vary appreciably among hospitals and it is critical to include this data. What if the mortality data showed that hospitals with C-section rates below 25% have higher perinatal mortality rates than hospitals with higher C-section rates. If that were the case, the hospitals with lower rates should be chastised, not held up as a model for an ideal, achievable C-section rate.

    Here is a much better article on this topic, written by a renowned OB.

    http://www.newyorker.com/archive/2006/10/09/061009fa_fact

    • Martha Bebinger

      Hi Lisa – I completely agree that we need to focus on outcomes. It would be important to compare C-section rates to perinatal mortality, but we don’t have that data. Babies who die immediately after birth or within their first year of life are reported by town in Massachusetts. You can download the state’s birth report through this link if you are interested: http://www.mass.gov/eohhs/gov/newsroom/press-releases/dph/birth-report-shows-lowest-teen-birth-rate-in-history.html

      We also need to focus on outcomes for moms and the small but not irrelevant risk of complications that increases with each C-section.

  • Millicent Broderick

    Is it a fact that a woman increases her maternity leave by a number of weeks by having a C section? It is surgery after all. If that is the case and mothers are taking a risk in order to have more time at home with their babies then perhaps a look at this country’s maternity allowances should be examined. Our neighbor to the north, Quebec, Canada has an excellent system of one year maternity leave at 60% salary and job guarantee.

    • Danielle Nixon

      Nope. No extra maternity, just a slightly less enjoyable one.

    • guest.

      If a mother receives payment during a maternity leave under a short-term disability plan, you generally are considered “disabled” for 8 weeks with a c-section and 6 weeks with a vaginal delivery. However, this varies by health care professional.

      • Millicent Broderick

        Thanks

  • Lawrence

    All of my grandparents and their siblings lived in their own homes until their 90s where they were all born, not in a hospital at all.

  • Christine

    I had thought infection, anesthesia issues and blood clots were higher risks with c-sections than uterine rupture.

  • Erin Burke

    It’s totally a cultural thing at each hospital. And overly-managed care during labor often turn normal births into abnormal situations. I feel very fortunate to have given birth to both my children at Tobey Hospital in Wareham with an excellent midwife, Louise Bastarache. Many institutional factors at Tobey likely contribute to their low C-section rate – the presence of midwife care, the availability of tubs to labor in, a nursing staff that’s used to more hands off labor management. I can’t say enough good things about Tobey and my midwife. And that care shows in the hospitals section rate.

    • Jenifer Holloman

      does Tobey Hospital still have a VBAC ban?

      • Erin Burke

        Jenifer – Tobey does still have a VBAC ban because they’re part of the Southcoast Hospital System. And I couldn’t actually birth in the tub. That was another ban. I could labor there but had to get out to birth. Despite these issues, the situation at Tobey and with Louise is leaps and bounds better than many other places

  • Chris Just

    I chose to have my children at the Cambridge Birth Center after hearing extremely positive feedback from those who had given birth there. Each of my birth experiences was incredibly rewarding due to the exceptional, personalized care provided by the nurse-midwives and the nurses that work there. The rooms are beautiful and the jacuzzi was heavenly. I felt safe as I knew that if my care needed to change I could be immediately transferred to the hospital across the street.

  • Lawrence

    Why put your child at a disadvantage by having a C-Section if it can be avoided?
    20% increase in asthma and other complications is just the beginning.