What’s behind San Diego County’s alarmingly high C-section rates?

Nearly one in three first-born babies in San Diego County is delivered by cesarean section surgery, a rate that is far higher than what federal health officials say it should be.

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Hospitals are now under pressure to reduce cesarean sections, which carry more risk of complications than vaginal delivery.[/box][/one_half]

What’s more, San Diego County’s rate is higher than all other urban counties in the state. Also, every local hospital except UCSD Medical Center and Scripps Mercy Hospital San Diego exceed the 23.9 percent national target. The higher rate is of concern because C-sections carry much greater risks of complications, including infections and lacerations, than do vaginal births.

The county’s high rate was driven in part by Sharp Mary Birch Hospital for Women and Newborns, where more babies are born than at any other hospital in California. Sharp Mary Birch’s rate of 33.8 percent was the second highest in California and the 20th highest nationally among hospitals with the highest volumes of low-risk babies.

The county’s high rate also was driven by Scripps Memorial Hospital’s 33.2 percent C-section rate, the second highest in the county.

Those statistics came to light in a Consumer Reports publication that analyzed national 2014 C-section rates for women at low risk of complications — that is, women delivering their first baby: a single child whose head is in the normal down position in the birth canal. inewsource calculated the number of C-sections in these low-risk groups for each hospital to compute a rate for each county.

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Although these births are often safer through a vaginal delivery, impatience and poor understanding of recent changes in recommendations for safer obstetric practices have kept C-section rates too high around the country, and in San Diego in particular. The county’s rate, based on statistics collected by the California Maternal Quality Care Collaborative, is 29.7 percent.

“You can think of this issue as part of the larger cultural issue of over-utilization that we have in this country,” said Doris Peter, director of the Consumer Reports Health Ratings Center.

“It’s a shocking thing, that only 40 percent of hospitals met the target rate nationally,” Peter said. She said labor and delivery floor managers told her staff they very much wanted to lower their C-section rates, but they “didn’t have the support from leadership to implement better procedures and guidelines” to stop doctors from performing C-sections prematurely, or when they weren’t necessary.

Now, the U.S. Department of Health and Human Services is making a national push to reduce C-sections.

Asked why Sharp Mary Birch had such a high C-section rate, Dr. Colleen McNally, the hospital’s chief medical officer, acknowledged the problem, saying doctors and nurses there have moved too fast to deliver a baby by C-section.

Now, they’re being encouraged to wait a little longer for a woman to deliver naturally, as long as the newborn is getting enough oxygen and has a normal heart rate.

McNally said hospital revenue is not the issue, because the net cost of a vaginal delivery and a C-section is about the same. Others who have looked at the issue say it’s not clear which delivery method makes more money for a hospital, and that it may depend on who the payer is, for example, straight Medi-Cal, Medi-Cal managed care, or a commercial health plan.

“We know our rate is high, and we’ve been consistently working on it,” she said, adding that in recent months, it has started to drop. That might be because in January the hospital began publishing C-section rates for mothers in this low-risk group by each physician’s name in the doctor’s lounge. “Everyone’s rate is posted in big black letters. It is all transparent,” she said.

In the past, she said, doctors with higher rates justified them by saying their patients are sicker, obese or older. But with the public posting, they can look at their numbers and see “they’re all sharing the same (kinds of) patients, and their rates should be similar.”

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Dr. Dale Mitchell, chairman of the obstetrics and gynecology department at Scripps Clinic, whose doctors deliver two-thirds of Scripps Memorial’s babies, attributed its high C-section rates in part to La Jolla’s demographic.

These women are older, he said. “They’re highly educated and come in with a very set idea of what they want their experience to be. They’re averse to risk and very averse to even assisted vaginal delivery, telling us up front that they don’t want vacuum or forceps, and that takes away a tool we might have,” Mitchell said.

Lastly, he said, La Jolla’s biotech industry brings a lot of international patients who have “expectations that are a little different.”

“There is some pressure,” Mitchell said “ They have a set birth plan in mind.”

Scripps is now “allowing extra time for labor, and trying to support natural childbirth when we can,” including educating our providers and nursing staff, as well as patients, he said.

Scripps also has started placing a list of each physician’s C-section rate on the wall of the physician’s lounge and elsewhere so they can see whether patients really met criteria for a C-section.

”Here, in San Diego, many women and their obstetricians have been more interested in neat and tidy, Amazon-package-delivered birth than in other areas of the state where other forms of labor and tolerance of slower labor progress are cherished.”— Dr. Thomas Moore

Dr. Thomas Moore, professor of maternal-fetal medicine at UCSD Medical Center, which had the lowest C-section rate in the county at 23.2 percent, said the overall high rates in San Diego County should be “a wake-up call” for hospitals and obstetricians.

What the data tell us “is that in our desire to please our mothers and families, we may have been giving in to a misunderstanding about what normal labor is, and instead doing these extra C-sections (and causing) net harm. … Many of our obstetricians are just learning these new facts.”

Specifically, hospitals in the San Francisco Bay Area have much lower C-section rates, he said. San Francisco County has a 20.8 percent rate, Contra Costa 23.1 percent, Sonoma 21.9 percent, San Mateo 25.5 percent and Alameda 23.7 percent.

“Those (Bay Area) women are saying, ‘Don’t do a C-section. Give me more time,’” Moore said. Also, many Northern California hospitals more aggressively advocate the use of “midwives and doulas who sit with the patient and help them understand that, no, we’re not tired of it, this is in the normal range, lowering the patient’s stress.”

The north-south difference in the state also can be seen within the 27 Kaiser Permanente hospitals. Among the 15 Kaiser hospitals in Northern California, only one is higher than the national target of 23.9 percent. But among the 12 Kaiser facilities in Southern California, half are higher than the national target, and San Diego’s Kaiser Permanente, with a 30 percent C-section rate, has the health plan’s highest rate.

Moore put some of the blame for San Diego’s high rate on mothers-to-be and their families. “A lot of patients have their lives so scheduled. And that uncertainty factor of when you’re going to go into labor is not welcome for many women,” he said.

But physicians here share some of the blame too, Moore said. “There’s also a money and convenience feature for the physician,” he said. “Often, the doctor wants the baby born at 7 o’clock in the morning (to allow them to see scheduled patients in their offices). So we let her labor all night but at 7 we’re doing the C-section, no matter what.”

Additionally, “doctors sense that patients don’t want a long labor, even if it’s progressing appropriately,” he said.

“The patients get impatient, their spouses and moms get impatient. They ask, ‘Why aren’t you doing something? Why can’t we do this now?’ We end up with C-sections that aren’t necessarily the best way,” he said.

Moore noted that the protocols for how a natural labor progresses have been changing over the years and were made official two years ago with a consensus statement from the American College of Obstetrics and Gynecology.

But many hospital practices have not caught up.

“You can think of this issue as part of the larger cultural issue of overutilization that we have in this country.” — Doris Peter of Consumer Reports

The old rule was that a woman at 3 centimeters dilation should increase dilation by 1 centimeter per hour, at a minimum. “And if you don’t move at all for at least two or three hours, that’s seen as an obstructed labor and you should do a C-section so the mother doesn’t get infected and the baby doesn’t go to the neonatal intensive care unit.”

Now, the guidelines say the pace of dilation should not be a concern until the woman is at 6 centimeters. The guidelines also extend the time a woman should push from two hours up to four, and only then should a C-section be considered.

“Now, we know (waiting longer) is normal labor progress, but some patients don’t want to know what’s normal. They want to go and get delivered. And meanwhile the nurses are looking over their eyeglasses at you,” Moore said.

The potential harms from cesarean deliveries are well documented for both mother and the fetus. The obstetricians organization’s consensus statement lists higher risks of severe postpartum bleeding, infections and sepsis, transfusions, uterine rupture, shock, cardiac arrest, acute renal failure, amniotic fluid embolism, placental abnormalities and a double risk of mortality for the mother. For the baby, the chance of laceration and respiratory problems are greater than with vaginal delivery.

Mitchell of Scripps and Moore noted that offering midwives and doulas to help support the mother in labor can also relieve stress and reduce C-sections. Mitchell said that in the past, “we weren’t proactive about it.” Now Scripps is recommending that all first-time moms “consider the use of a doula” or a midwife.

Added Moore: “Every patient who comes to UCSD can have us call a volunteer doula to be the labor companion for that patient, (because) we know that doulas hasten the progress of labor, and increase the likelihood of a vaginal birth.”

Dr. Neel Shah, assistant professor of obstetrics at Harvard Medical School and executive director of Cost of Care, a national physicians’ project to reduce unnecessary medical procedures, is involved in a national project to reduce C-sections. And even with such high national numbers, the Consumer Reports data show that “San Diego seems to be an outlier.”

He’s talked with more than 100 obstetric leaders across the country, including many in Southern California, to learn why some regions have much higher rates.

“There’s a baked-in incentive to do a C-section at all times … because most labor floors (in hospitals) are loss leaders, not cash cows. They’re under-resourced and rarely have as many beds or staff as they would ideally want,” Shah said. And since labor floors never know when to expect their customers, “you have uncertainty.”

“And one way of establishing certainty, and alleviate pressure, is to expedite the procedure: Either wait for labor to proceed for several hours, or do a 30-minute C-section,” he said.

That’s an incentive everywhere, Shah said, but varies from place to place, “a function of how the labor floor is managed and how resources are allocated.”

Peter of Consumer Reports said the national target of 23.9 percent target is a conservative one. “There are experts who believe that hospitals should be able to go well below 23.9 percent.

“A lot of hospitals said things like, ‘Oh, we have complicated patients,’ or ‘We customize our services for our patients,’” which she said are excuses for not providing more appropriate care.

This story has been corrected to reflect that Scripps Mercy Hospital San Diego’s C-section rate of 23.6 percent also was below the national target. 

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