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
To see how Contra Costa Regional Medical Center in California made changes to support women who want to plan a VBAC, see the video
To find out more about what some hospitals are doing to reduce cesareans, see
For a list of support groups for mothers who experience psychological stress after a cesarean see,
To find out more about hospital intervention rates and what mothers think of their careproviders, see