Tag Archives: physician practice style

California Reseachers Call For Fewer Cesareans and More VBACs

30 Jan

In a recently published White Paper by the California Maternal Quality Care Collaborative researchers in California confirmed that the high number of cesarean sections performed in the United States and in California put mothers and babies at increased risks and add significantly to healthcare costs with little evidence of health benefits.

The report also confirmed that there are psychological costs that are often overlooked. Postpartum anxiety, depression,  and post-traumatic stress disorder (PTSD). Cesareans affect maternal-infant attachment and breastfeeding as well.  The cesarean rate in California and the United States increased by 50 percent between 1998 and 2008. It rose from 22 percent to 33 percent in ten years. Researchers found no data to document any population-level benefit to mothers or newborns associated with the  increased rate of cesareans.

The authors state, “Today providers seem to see no ‘downside’ to a high cesarean rate; and women seem increasingly accepting of the prospect of a cesarean.”

California healthcare payers pay hospital charges of $24,700 for a cesarean compared to $14,500 for a vaginal birth. The authors state physicians, healthcare payers, employers who pay for childbirth costs, and public health officials are not aware of the “disconnect” between the amount of dollars spent and the health outcomes in U.S. maternity care.

The authors of  Cesarean Deliveries, Outcomes, and Opportunity for Change in California: Towards a Public Agenda for Maternity Care Safety and Quality found that the increasing cesarean rates can be attributed to two main reasons: cesareans performed on mothers having their first baby and the dramatic decline in VBACs.

The number of cesarean performed during labor vary widely and reflect individual physician discretion rather than clear medical indications.  In fact researchers found that 90 percent of the variation in cesarean rates during labor is due to only two indications: failure to progress and non-reassuring fetal heart tones (fetal distress).  The number of cesareans performed for these two indications vary widely and depend on the physicians’ individual response to these two conditions.  Attitudes of physicians and nurses on the labor and delivery unit also play a part.

The White Paper showed that overall, hospital cesarean rates in California varied from 18 percent to over 50 percent of all births. Hospital cesarean rates for low-risk mothers giving birth for the first time varied from 9 percent to 51 percent. More recent data showed that in 2009 hospital cesarean rates in California varied from 16 percent at Sutter Davis Hospital in Davis to 68 percent at Los Angeles Community Hospital.

The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States, states, “Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes. There are no data that higher rates improve any outcomes, yet the CS rates continue to rise.” 

The argument has often been made that hospitals with high cesarean rates have a higher proportion of high-risk births and that rising cesarean rates are due to “maternal request.” This report clearly shows that there is no foundation to these arguments.

With regard to the decline of  VBACs, researchers say it will take persistent pressure from childbearing women and advocates for evidence-based practice in childbirth, public reporting of  hospitals who support VBAC and increased awareness by childbearing women about the safety and benefits of VBAC. Citing a national survey  of women’s experience of childbirth, the authors found that reality-based television shows on childbirth and many websites send an incorrect message that cesareans are easy, pain-free, and risk-free. Most women have very little knowledge of  common hospital procedures and their impact on the normal progress of labor.

Based on interviews of California careproviders, the report found that VBAC is also “not popular” with physicians due to the longer time commitment needed for a vaginal birth and their perception of increased liability.

“Whatever the motivation for today’s more ‘defensive’ approach to delivery,” the authors state, ” it is not resulting in better outcomes for babies or their mothers.”

The White Paper is an extensive and insightful study of the rising cesarean rate in California, the health risks of surgical birth, the medical factors driving the trend, and the socio-cultural factors that keep cesarean rates high. It also dispells several myths about cesarean section.

The report includes a valuable, multi-faceted response to reducing cesareans. Strategies include, quality improvement measures, examining hospital practices that lead to cesareans, public reporting of hospital cesarean and VBAC rates, payment reform, and an education campaign to increase awareness about the short- and long-term health risks of cesareans for mothers and babies.

The authors make a  strong recommendation to use several facility-appropriate approaches at the same time since many of  “these interventions interact positively with and reinforce each other, making the whole greater than the sum of its parts.”

The White Paper is a collaborative report by researchers from the California Maternal Quality Care Collaborative, the Pacific Business Group on Health, and the California Perinatal Quality Care Collaborative.



To find out more about reducing the odds for “failure to progress,” during labor, see

Six Lamaze Healthy Birth Practices

To see how Contra Costa Regional Medical Center in California made changes to support women who want to plan a VBAC, see the video

The Birth After Cesarean Improvement Project

To find out more about what some hospitals are doing to reduce cesareans, see

Michigan Health & Hospital Association Keystone Center- Obstetrics

Sutter Health, California,

West Virginia Perinatal Partnership- First Baby Clinical Initiative

For a list of support groups for mothers who experience psychological stress after a cesarean see,

Support Groups 

To find out more about hospital intervention rates and what mothers think of their careproviders, see

The Birth Survey

Elective Inductions, Cesareans, and Preterm Birth

20 Nov

November is Prematurity Awareness Month when the March of Dimes (MoD) encourages care providers and the public to focus on the high number of preterm births in the United States and what can be done to reduce them. The March of Dimes, along with state and national health services are concerned that increasing elective inductions and scheduled cesareans may be contributing to the rising number of babies born preterm. Premature birth is the number one cause of newborn death in this country.

In addition to encouraging women to stop smoking, avoiding multiples from fertility treatments and providing progesterone treatments for women with a history of preterm birth, the MoD recommends avoiding unnecessary cesareans and inductions before 39 weeks and encourages women with a healthy pregnancy to wait for labor to begin on its own.

Between 1990 and 2006  the number of babies born after 39 weeks decreased sharply and the number of babies born between 36-38 weeks gestation rose sharply. Experts associate this trend with increasing rates of induction of labor and cesarean sections. An integrated health care system based in Salt Lake City, Utah reported that in 2001, 28%  of their elective deliveries were performed prior to 39 weeks.

In 2008 12.3%  of all U.S. births were preterm. Based on records from the National Center For Health Statistics, the March of Dimes developed a score card for national and state preterm birth rates. Comparing the  national preterm birth rate to the Healthy People 2020 goal of 7.6%  the MoD gave the U.S. a “D” grade.

Preterm birth is defined as a live birth before 37 completed weeks gestation. A baby born between the 34th and 36th week of pregnancy is considered  late preterm. A full term pregnancy is 40 weeks. When cesareans are scheduled or labor is induced there is a margin of error in pinpointing fetal maturity. Being born only one week earlier can make a difference in terms of complications babies are likely to suffer.

The number of cesareans increased by 71% between 1996 and 2007. The rate rose for women in all age, racial and ethnic groups. The National Center for Health Statistics  found that non-medical factors including physician practice style and women’s preferences contributed to the widespread and continuing rise of cesareans (NCHS Data Brief No. 35, March 2010).

A large percentage of the increase in preterm and late preterm singleton (one baby) births between 1996 and 2004 occurred among women who delivered by c-section.

The last few weeks of pregnancy are extremely important to a baby’s health because many organs, including the brain and lungs, are not completely developed yet. Babies born a few weeks too soon can face serious health challenges and are at risk for lifelong disabilities, such as cerebral palsy, lung problems, vision and hearing loss, and learning disabilities.

Expectant mothers however, are not aware of the importance of keeping the pregnancy full term. In a recent U.S. survey over 90% of women believed that giving birth at 39 weeks was safe, unaware of the crucial brain development that occurs in the last weeks of pregnancy. Women who agree to or choose to induce labor or schedule an elective cesarean don’t consider the additional interventions and days in the hospital that premature babies often need nor are they aware of the financial costs.

Elective inductions also increase the risk for cesarean section.

A national campaign is in full force to educate care providers, hospitals, and the public about the importance of maintaining a full term, 40 weeks, pregnancy. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the national body that accredits hospitals, recommends that hospitals track and reduce their induction rates as one criteria to gain accreditation.

On November 15, 2010 the Mineapolis – St. Paul Star Tribune reported that the Minnesota State Department of Human Services is leading the nation in discouraging birth by convenience. It has  created a policy against elective, non-medically indicated inductions by asking hospitals to establish policies to reduce convenience inductions by the year 2012.

Although the national preterm birth rate dropped 3% in the last two years, the U.S. still has one of the highest preterm birth rates in the world. Hopefully, the progress that has been made in the last two years will continue.

For additional information on the impact of labor induction and preterm birth see, Labor Induction Exposed, posted November 15, 2010 on Mother’s Advocate Blog.

Sources for this article:

March of Dimes/California Maternal Quality Care Collaborative, Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age, A California Tool Kit To Transform Maternity Care.

March of Dimes, 2010 Prematurity Birth Report Cards

March of Dimes, www.prematurityprevention.org

March of Dimes, Professional Resources

Educational Resources

U.S. Surgeon General Dr. Regina Benjamin’s message on preterm birth, video

March of Dimes, Why The Last Weeks of Pregnancy Count

Lamaze International, Let Labor Begin On It’s Own

Mother’s Advocate, Let Labor Begin On It’s Own, video