Cesarean Births Continue to Rise

New report suggests reforms needed to reverse the trend

Cesareans increase rates of surgical complications, infections, risks in future pregnancies and spending, according to research from the California Maternal Quality Care Collaborative.

December 8, 2011

In California, surgical delivery of babies, also known as cesarean delivery, has jumped 50% over the last decade with no demonstrated improvement in outcomes over normal vaginal childbirth, according to a new study released today.

Cesarean deliveries now account for 32% of births in California, raising the potential for increased rates of surgical complications, infections, risks in future pregnancies, and much higher costs to patients and society, the report said.

While cesarean deliveries are often performed for medically necessary reasons, the report from the California Maternal Quality Care Collaborative (CMQCC) identified dramatic geographic variation with rates ranging from 9% to 51% among low-risk women having their first baby. This large variation among California regions and hospitals cannot be explained by medical factors alone and therefore suggests that labor management practices and local attitudes help drive the use of cesareans during labor.

Reasons for the increase also include: physicians' concerns about medical liability and avoidance of risk, as well as specific labor practices such as the increased reliance on labor induction, early labor admission, lack of patience in labor, and the virtual disappearance of vaginal birth after a prior cesarean, the report found.

"Over the last 15 years, cesarean deliveries have become so common that in some hospitals and communities they are considered 'normal births' despite the increased risks," said Dr. Elliott Main, medical director of the CMQCC and a practicing obstetrician.

"The most serious and often overlooked risk for a woman having a first cesarean is the increased likelihood of having a cesarean delivery in subsequent pregnancies. Currently, in California, if a woman has her first birth by cesarean, over 90% of all her subsequent births will also be by cesarean, each with escalating risks," said Dr. Main.

Undergoing multiple cesarean deliveries markedly increases the chances for complications, such as life-threatening hemorrhage due to placental implantation problems.

There is also strong evidence that babies born by cesarean delivery, without the contractions of labor (i.e., scheduled), have significantly higher rates of neonatal respiratory problems than those born vaginally.

Commercial reimbursement for a cesarean is higher than the amount for vaginal birth — $18,800 compared to $11,500. The Pacific Business Group on Health (PBGH), a co-author of the study, estimates that these additional cesareans cost public and private payers in California at least $240 million in 2011 alone. An effort to reduce cesareans could save California between $80 million and $441.5 million a year, depending on the number of cesareans prevented.

However, the study says that reducing cesarean deliveries will not be easy and a multi-pronged set of strategies will be required. The study recommends that hospitals, doctors, and insurance companies (including Medi-Cal, which pays for over half of the births in California) band together to develop quality improvement efforts to reduce first-birth cesareans among low-risk women.

The program would need to include sharing best practices with real-time benchmarking; public reporting on a balanced set of quality measures; payment reforms to eliminate incentives for cesarean delivery; and broad-based, statewide educational outreach to foster a balanced view of cesarean delivery and its short- and long-term consequences.

With planning grant funds from the California HealthCare Foundation (CHCF), which also funded this report, CMQCC is leading an effort to develop a California Maternal Data Center to achieve these goals. The project has recently received major funding for statewide implementation from the US Centers for Disease Control and Prevention's Division of Reproductive Health.

"To help hospitals and doctors in their efforts to improve pregnancy outcomes, we need a robust source of timely maternity care data," said Dr. Main. "Once the data are vetted, we will want to share the results with women so they can make informed decisions."

The report, Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality, is available on the CMQCC website through the External Link below.

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