Reducing Unnecessary C-Sections in California

Why This Work Matters

Childbirth is the number-one reason for hospitalization in California and the US. In California, there are 500,000 births each year (one-eighth of all US births), half of which are paid for by Medi-Cal. In the past decade, the cesarean-section (c-section) birth rate has risen by 50% nationwide. Today, one-third of all babies are born via surgery — significantly more than the federal Healthy People 2020 goal of 23.9% for low-risk deliveries. This upward trend is seen across all demographics, and California hospitals show significant, unwarranted variation (ranging from under 15% to above 60%) in the number of c-sections performed.

Overuse of c-sections matters because, while often lifesaving in limited circumstances, the surgery also brings serious risks for babies (such as higher rates of infection, respiratory complications, and neonatal intensive care unit stays, as well as lower breastfeeding rates) and mothers (such as higher rates of hemorrhage, transfusions, infection, and blood clots).

Additionally, once a mother has had a c-section, she has a greater than 90% chance of having the procedure for subsequent births — leading to higher risks of major complications, such as hysterectomy and uterine rupture. Unnecessary c-sections also drive up costs of care. The total average payment for c-sections is nearly 50% higher than for vaginal births, not including associated costs (for example, hospital readmissions, home care, and subsequent c-sections).

Our Goal

As part of our emphasis on high-value care, CHCF has launched an initiative to lower the state’s c-section rate for low-risk mothers to under 23.9% by 2020. To bring about this change, CHCF is funding projects in the areas of data and transparency, quality improvement, payment change/purchaser requirements, patient engagement, and information and analysis for decisionmakers. Taking advantage of significant statewide momentum, we are building on a successful pilot (PDF) in three Southern California hospitals that reduced low-risk c-section rates by 20% in less than one year.

CHCF is working with many partners that are actively engaged on this issue, including but not limited to: the California Department of Health Care Services, California Maternal Quality Care Collaborative, California Public Employees Retirement System (CalPERS), Consumer Reports, Covered California, Hospital Quality Institute, Integrated Healthcare Association, Pacific Business Group on Health, and both state and national specialty provider societies.

Project Highlights

  • Data & Transparency: Valid, reliable, and timely performance data are critical. With the low-cost, low-burden California Maternal Data Center, providers can track key maternity measures at the hospital level, as well as drill down to physician and patient data. Hospital-level metrics are also publicly available at
  • Quality Improvement: Providers need help to lower c-section rates. The California Maternal Quality Care Collaborative developed a toolkit for providers, and is running a statewide quality improvement initiative for implementation in California hospitals.
  • Patient Engagement: To make informed care choices, patients need to understand both the benefits and substantial risks of undergoing a c-section, as well as the variation that exists in quality of care. CHCF helps to make maternity care quality metrics publicly available on and is partnering with consumer-focused organizations, such as Consumer Reports and Yelp. CHCF also aims to reach women by partnering with University of Southern California’s Hollywood Health and Society to incorporate more accurate depictions of maternity care into TV programming.
  • Payment Change & Purchaser Requirements: Some payers are paying more for c-sections than vaginal deliveries. CHCF is supporting projects to address disconnects in the marketplace and align incentives with desired outcomes, such as efforts with Integrated Healthcare Association, Smart Care California, and Pacific Business Group on Health (PBGH).
  • Informing Policymakers: Medi-Cal pays for half the births in the state, making maternity care an important policy issue. CHCF educates Sacramento legislators and their staff via briefings and publications.

Background on Maternity Care in California

  • CHCF Almanac report describes the status of maternity care in the state, including available statewide data that relates to maternal mental health. (June 2016)
  • The Listening to Mothers in California survey is an effort to collect the opinions and experiences of mothers about maternity care. Co-funded by the Yellow Chair Foundation, and conducted by a team led by the National Partnership for Women and Families, the survey is being fielded in English and Spanish. It is based on the widely cited Listening to Mothers survey that has been conducted multiple times nationally, but never before at the state level or in Spanish. (In process, with findings expected Q2 2018.)

Learn More

For more information, contact CHCF’s Stephanie Teleki.