C-Sections: Are There Too Many? : Southland Caesarean Birth Rates Above Optimum, Health Experts Say

The vast majority of hospitals in Los Angeles, Orange and San Diego counties report Caesarean section birth rates significantly above what health experts call optimal, according to a Times analysis of Southern California hospital records.

Rates at some hospitals, the research shows, are double those characterized by several Caesarean-policy experts as a justifiable upper limit.

And while a national controversy over the Caesarean birth rate has not resulted in a consensus on how much is too much, the situation in Southern California parallels that in other population centers, leading a health care consumer group to charge that hundreds of thousands of unnecessary surgical births occur in the nation, the state and the region each year.

The consumer organization, the Ralph Nader-affiliated Health Research Group, charges in a recent report--based on national data, trends in 10 states including California and specific hospital rankings in Maryland--that 455,000 “unnecessary” Caesareans occur in the United States each year. The organization contends that 45,292 unnecessary Caesareans occurred in California in 1985.

“It is clear that the increase in the Caesarean section rate shows no sign of slowing down, despite soundings of alarm by organizations and physicians for several years,” the Health Research Group concluded. “Additional action outside the medical profession is urgently needed.”

Corrective measures recommended by the group ranged from far greater availability of vaginal delivery to women who have had Caesarean deliveries to better hospital surveillance of the practices of individual doctors.

Times’ Ranking Told

A ranking of Caesarean rates at Southern California hospitals--developed by The Times from data collected by the California Department of Health Services Maternal and Child Health Data Base--adds immediacy and intensity to the dispute. (The data were prepared and analyzed by the Community and Organization Research Institute at UC Santa Barbara.)

Between 1970 and 1985, the California Caesarean rate--mirroring national trends--rose from just over 6.5% to 21.6% of all babies delivered in the state. (The 1986 rate is not yet available for California.)

In Southern California, statistics for hospitals operating delivery facilities show rates in the region mirror those of the state. For 1984--the last year for which hospital-by-hospital figures are available--the state Caesarean rate was 20.9%, while Los Angeles County recorded 21%, Orange County had 23.7% and San Diego County, 20.2%.

Some area hospitals recorded rates significantly higher than the county averages.

‘Just Numbers’

The Hospital Council of Southern California--expressing concern about publication of the comparative ranking--emphasized that consumers should be “extremely cautious about interpreting raw data in terms of quality of care.”

In a sense, said David Langness, a hospital council spokesman, the rates at hospitals here are “just numbers.”

Highest Ranking

In the Times-prepared rankings, the AMI Tarzana Regional Medical Center had the highest rate in Los Angeles County--39.1%. The facility is owned by American Medical International, a large for-profit chain. In Orange County, Coastal Communities Hospital in Santa Ana had the highest rate, 33.9%, and in San Diego County, Scripps Memorial Hospital in La Jolla led with 37.6%.

AMI Tarzana’s director of maternal-fetal medicine, Dr. Barry Schifrin, said the hospital is “very definitely concerned about the rate itself, but the problem is there is no evidence the rate is in any way related to the (quality) of obstetrical care. The problem is that this can never be quantified.”

Some Hold Rate Down

But still other hospitals--including several large academically affiliated medical centers that deliver many high-risk babies but have strong Caesarean-control programs--have held rates down. Of these, UCLA Medical Center reported 16.4%; Martin Luther King Jr. Drew Medical Center, 13.3%; the Kaiser Foundation Hospital in Anaheim had 16.8%, and the Naval Regional Medical Center in San Diego, 12.2%.

There was little difference in Caesarean rates between for-profit and not-for-profit health centers. However, hospitals owned by county governments, University of California hospitals and those operated by the Kaiser Foundation Hospitals all had rates significantly below the statewide average.

Perhaps the most significant factor influencing the Caesarean rate, many experts agree, is the practice of performing Caesarean sections in each subsequent delivery after a woman has had a first. The practice follows an old medical dictum: “Once a section, always a section.” Dr. Warren Pearse, executive director of the American College of Obstetricians and Gynecologists, a leading professional group, said an appropriate Caesarean section rate would be between 12% and 15% of all births. But Pearse refused to join in characterizing anything over that as “unnecessary.”

“I believe the rate can be reduced and there are a number of ways it could be in today’s climate,” he said. “A large factor is that women themselves insist on Caesareans. Nobody will believe that’s true, but it really is. We think the rate could be reduced, and we’ve certainly tried to do it. But we can’t disagree that we’ve had no measurable impact.”

In defending apparently elevated Caesarean rates, Langness contended that recommendations that Caesarean rates remain in the 10%-to-17% range--the consensus among national experts questioned by The Times--are unrealistic.

“We would say that a 10% rate is dangerously low and it’s dangerous not in the immediate sense (in terms of what happens during the delivery) but in the later sense as it relates to brain functioning of a growing child,” Langness said. Brain damage that is not apparent until age 3 or later could be caused by oxygen deprivation during delivery.

Explanation in Dispute

But even some top local hospital medical officials took issue with that justification.

These experts, including Dr. Calvin Hobel, director of maternal health at Cedars-Sinai Medical Center, dismissed the latent brain injury theory as an unproven--possibly illogical--contention that contrasts with the experiences of countries with Caesarean rates significantly lower than the United States.

“It’s hard to compare one hospital with another,” said Hobel, whose hospital had a 1984 rate of 24%--higher than “optimal,” but lower than some local observers had expected.

“Hospitals with teaching programs (like Cedars) tend to have lower C-section rates,” he said. “Physicians are more concerned about making certain that sections are done only when they meet very specific criteria.”

Other Influences

But on the other hand, Hobel said Cedars and other health centers also must grapple with conflicting influences that tend to keep Caesarean rates stubbornly high.

“I think there is (doctors’) concern with malpractice,” he said, “and in terms of vaginal births after Caesareans, it’s quite difficult to change people in terms of the way they manage patients. It just takes a long time to persuade (doctors) that it’s safe and a reasonable approach.”

The national Caesarean rate has risen nearly in lock step with that in California--from 9.1% in 1974 to 24.1% in 1986--even though a National Institutes of Health task force severely criticized the developing increase in a 1980 report and urged doctors to take specific steps to reverse the trend.

But the problem has resisted solution. Hobel and other experts said the proportion of comparatively older women giving birth entails greater risks of complications during labor and may contribute to keeping Caesarean rates high.

“I’m convinced that older women, after age 28, have more difficulty in labor, so there are things that make this question more complex,” Hobel said.

Medical Basis Questioned

Dr. Bruce Flamm, of the Kaiser Foundation and UC Irvine and principal author of a new study on Caesarean sections, said his research and work in the Kaiser hospital system implies that a major part--perhaps all--of the Caesarean rate increase since 1970 lacks a justifiable medical basis.

“I don’t think things have changed very much as far as maternal (death and complication rates) are concerned,” Flamm said. “So I don’t think we’ve done much except change our Caesarean section rate to 25%.”

In recent years, many studies--including Flamm’s, have found that a successful vaginal birth after a previous section is possible for more than 75% of women attempting it.

In Flamm’s study and one other published this month in the journal Obstetrics and Gynecology, doctors in Orange County and Memphis found new drug-use and delivery techniques make it possible for women to deliver vaginally even though they had previous Caesareans.

Risk Is Small

There is a small risk of rupture of the uterus in a vaginal delivery after an initial Caesarean, Flamm said, but maternal or infant deaths from such events have been rare in recent years and vaginal-after-Caesarean birth is widely viewed as an extremely safe procedure that avoids exposing a woman and her child to the risks of abdominal surgery.

Experts agree a Caesarean is called for if a woman in labor is having severe enough difficulty that her health and the health of her baby are at risk. If a baby develops fetal distress, an indication of potential defects or complications, a Caesarean is also justified, they say.

Statewide, Kaiser hospitals achieved a 1984 Caesarean rate of 17.9%, a development Flamm said has been the result of more aggressive in-hospital review of Caesarean sections performed by staff physicians and much more frequent use of vaginal birth after initial Caesarean deliveries.

(Because of peculiarities in use of data entry codes, California figures used by The Times do not permit differentiation between initial Caesareans and those performed subsequently. The state data are collected from standardized birth reporting forms.)

Turning Babies Could Help

Flamm and Hobel also said they see great promise in growing experimentation with techniques in which babies that show signs of emerging in the breech position are maneuvered in the final weeks of pregnancy so they can be born in the normal head-first position.

“Even if all the breeches were turned successfully, it wouldn’t reduce the rate dramatically,” Hobel said, “but it would be a contribution.”

Dr. Mortimer Rosen of the Columbia University College of Physicians and Surgeons in New York said the “sadness” behind the stubbornly high Caesarean rate is that the stereotype of physicians trying to avoid malpractice suits is an accurate depiction.

Rosen, who chaired the NIH task force, said in a telephone interview: “I would be happier (if I could say) the fear of delivering a brain-damaged child is the motivating factor. But what the physician is bothered by is the risk and worry (in terms of litigation) of ‘what if the delivery does not come out well?’ ”

Rosen declined to play the Caesarean rate numbers game. But he said, in general, that at a hospital whose rate is greater than 20%, “something is wrong unless you have a unique explanation.”

But, calling himself an optimist, Rosen said: “The rate is going to stop somewhere. The public is going to have to become involved. There should be outrage that the rates are so high, and the public should be asking questions as to why of all doctors and hospitals.”

Financial Incentives

Dr. Sidney Wolfe, director of the Health Research Group, reiterated a charge common among critics of the existing surgical birth system, contending that financial incentives--Caesareans bring in more money in fees and require less of a doctor’s time than vaginal births--may be a key factor keeping Caesarean rates high.

In its report criticizing allegedly unnecessary Caesareans, the group found California’s Caesarean rate to be about in the middle of a 10-state scale that ranged from Wyoming (18.5% overall) and Iowa (19.7%) to Maryland (26.6%) and the District of Columbia (30.1%). In addition to the purportedly excess Caesarean total in California, the group found New York, with a 24.2% rate, to have had 30,026 questionable procedures in 1985.

The group’s report was written by Wolfe and co-authors Craig Tanio and Dr. Marc Manley.

“Every study shows that reimbursement level is an important element,” Wolfe said. “The lower the reimbursement rate, the lower the C-section rate. In terms of money, it is estimated that three-quarters of a billion dollars is spent unnecessarily every year on C-sections. In California, that would mean $72 million was wasted doing unnecessary C-sections in 1985 or 1986.”

Langness of the hospital council took sharp issue with the financial allegation, contending that there is no evidence “or even any inference, that doctors and/or hospitals are doing more C-sections because it is a moneymaking procedure.”

Measures Called For

Among other things, the Health Research Group report called for state laws requiring disclosure of Caesarean rates for hospitals and individual physicians.

Wolfe said public disclosure of data like those released in his group’s report may eventually begin to influence practice patterns at hospitals and among individual physicians and might reduce Caesarean rates.

“People will get used to asking doctors and hospitals ‘What is your C-section rate?’ and demanding that they find out not only whether a trial of labor (after a previous C-section) is granted, but what percentage of women deliver vaginally,” he said. “For the first time, someone has started talking about what the right rate should be. Up until now, everyone has avoided that.

“I will bet that, by 1990, the C-section rate is lower in most places in the country than it is now.”

Fewer by Younger Doctors?

Dr. Donald McNellis, of the National Institute of Child Health and Human Development, said there is growing evidence that younger doctors who have finished their training within the last five years or so perform fewer Caesareans. McNellis and Hobel at Cedars-Sinai agreed that younger physicians are more inclined to offer an attempt at vaginal birth after a previous Caesarean than their older counterparts.

Both agreed younger doctors are less intimidated by the perceived threat of malpractice suits in vaginal deliveries that result in unsatisfactory outcomes.

“We’re in a transition period,” McNellis said, “where both physicians and patients are questioning the practice patterns.”

Dr. E. J. Quilligan, dean of the UC Irvine School of Medicine and an expert on Caesarean section rates and their interpretation, said an optimal average rate for all hospitals would probably be about 12%--with those that receive complicated and high-risk cases on a referral basis justified in having rates of about 17%. UC Irvine Medical Center recorded a 17.7% rate in 1984, according to state figures used in The Times’ rankings.

Repeat Sections a Factor

Quilligan agreed that litigation fear is a major factor influencing the behavior of doctors and hospitals. But he said the exponential effect of repeat Caesareans being done on top of rising numbers of initial surgical deliveries had also played a major role in what has happened in the last 15 to 20 years.

Quilligan dismissed contentions that higher Caesarean rates reduce incidence of subsequent brain damage--commonly manifested by cerebral palsy.

He said elective repeat Caesareans--those performed because a woman states a desire to have another after having first delivered a child surgically--are pushing rates upward as well. He also said an unstudied potential complication is that fetuses are developing to larger average sizes before delivery, resulting in a higher incidence of difficult labor simply because the baby is too large to pass easily through the vaginal canal.

“How big that increase is, is not really known,” he said.

Note of Caution

Quilligan said he too was troubled by the tendency to draw sweeping conclusions about excessive Caesarean rates.

“You’re dealing in large statistics, (but) each C-section is an individual patient,” Quilligan said.

“People need to examine with the individual why it was done. It’s like the old days when it was assumed that the best hospitals had the lowest rates. But there were always patients who didn’t get a section who should have.”

Times Medical Writer Robert Steinbrook developed the tabulations and assisted in the research for this story. Free-lance writer Kathleen Doheny also contributed to the story. 1984 HOSPITAL CAESAREAN SECTIONS

These are the Caesarean-section rates for births in Southern California hospitals in 1984, the most recent year for which statewide data is available. The statistics are based on an analysis of birth-certificate data by UC Santa Barbara health-policy researchers.

The 1980-1984 maternal and child-health data base contains the Caesarean-section statistics for all California’s hospitals. Copies are available from the Community and Organization Research Institute, 2201 North Hall, UC Santa Barbara, Santa Barbara, Calif. 93106. The descriptive narrative costs $20 and the statistical appendix, which contains the individual hospital data, costs $30.

% Ceasarean Births Sections STATEWIDE 449,300 20.9% LOS ANGELES COUNTY 149,012 21.0 Medical Center of Tarzana 2,058 39.1 Verdugo Hills Hospital, Glendale 868 34.2 Huntington Memorial Hospital, Pasadena 3,331 33.1 Inter-Community Medical Center, Covina 609 32.6 Torrance Memorial Hospital Medical Center 2,773 31.7 Valley Presbyterian Hospital, Van Nuys 2,615 31.7* Santa Monica Hospital Medical Center 1,823 31.6 Bay Harbor Hospital, Harbor City 532 31.0 Methodist Hospital of Southern California, Arcadia 1,078 30.8 Glendale Memorial Hospital 757 30.5 San Pedro Peninsula Hospital 572 30.5 St. Joseph Medical Center, Burbank 1,618 30.1 St. John’s Hospital and Health Center, Santa Monica 1,394 29.8 Foothill Presbyterian Hospital, Glendora 384 29.7 Beverly Hospital, Montebello 1,717 29.5 Memorial Hospital of Hawthorne 569 29.3 Brotman Medical Center, Culver City 592 29.2 Los Angeles Community Hospital 540 28.9 Northridge Hospital Medical Center, Northridge 2,161 28.7* Lincoln Hospital, Los Angeles 472 28.6 West Covina Hospital 738 28.6 Hollywood Presbyterian Medical Center 2,200 28.5 Garfield Medical Center, Monterey Park 2,516 26.8 Burbank Community Hospital 218 26.3 Granada Hills Community Hospital 877 26.3 Holy Cross Hospital, Mission Hills 2,277 26.3 Mission Hospital, Huntington Park 1,081 26.2 Serra Memorial Health Center, Sun Valley 868 25.8 Pomona Valley Community Hospital 1,445 25.5* Valley Vista Hospital, San Gabriel 506 25.3 Little Company of Mary Hospital, Torrance 2,325 25.2* Queen of the Valley Hospital, West Covina 3,351 24.7 Westlake Community Hospital, Westlake Village 603 24.7 Pioneer Hospital, Artesia 874 24.4 Queen of Angels Medical Center, Los Angeles 1,556 24.3* Antelope Valley Hospital Medical Center, Lancaster 1,989 24.2 Memorial Hospital Medical Center, Long Beach 4,941 24.2* Cedars-Sinai Medical Center 5,650 24.0* Medical Center of La Mirada 1,659 23.9 East Los Angeles Doctors Hospital 676 23.4 Glendale Adventist Medical Center 2,104 23.4* Memorial Hospital of Gardena 1,425 23.2 St. Francis Medical Center, Lynwood 1,227 23.0* Los Altos Hospital, Long Beach 940 22.9 AMI San Dimas Community Hospital 708 22.7 Doctors Hospital of Lakewood 797 22.1 French Hospital of Los Angeles 1,075 21.9 Santa Marta Hospital, Los Angeles 840 21.8 Greater El Monte Community Hospital 591 21.4 Daniel Freeman Memorial Hospital, Inglewood 879 21.2* Dominguez Medical Center, Long Beach 1,133 21.1 Whittier Hospital 1,217 21.1 Kaiser Foundation Hospital, Harbor City 2,023 20.9 Maxicare Medical Center 1,278 20.6 St. Mary Medical Center, Long Beach 1,597 20.6 California Medical Center, Los Angeles 2,265 20.5 Long Beach Community Hospital 920 20.1 Kaiser Foundation Hospital, Panorama City 2,769 19.7* Centinela Hospital Medical Center, Inglewood 2,848 19.6* Orange Grove Community Hospital, Pomona 922 19.5 Charter Community Hospital, Hawaiian Gardens 521 19.0 Kaiser Foundation Hospital, Bellflower 4,523 18.9 Kaiser Foundation Hospital, West Los Angeles 1,991 18.4 AMI Glendora Community Hospital 931 18.0 Rio Hondo Memorial Hospital, Downey 774 18.0 Downey Community Hospital 678 17.9 Charter Suburban Hospital, Paramount 605 17.0 UCLA Medical Center, Westwood 2,164 16.4* Monterey Park Hospital 1,228 16.3 Naval Regional Medical Center, Long Beach 1,407 16.1 AMI Medical Center of North Hollywood 259 15.8 White Memorial Medical Center, Los Angeles 3,206 14.0* Lakeview Medical Center, Lake View Terrace 802 13.3 Martin Luther King, Jr. Medical Center 6,405 13.3* Kaiser Foundation Hospital, Los Angeles 4,165 11.7 County-USC Medical Center 16,465 10.6* Harbor UCLA Medical Center, Torrance 5,502 9.0* Humana Hospital: West Hills, Canoga Park 1,098 8.9 Bellwood General Hospital, Bellflower 581 6.7 ORANGE COUNTY 35,347 23.7 Coastal Communities Hospital, Santa Ana 1,207 33.9 Humana Hospital Huntington Beach 679 32.4 Mission Community Hospital, Mission Viejo 1,696 29.5 Hoag Memorial Hospital Presbyterian, Newport Beach 2,253 29.2* Martin Luther Hospital Medical Center, Anaheim 2,532 28.3* Western Medical Center, Santa Ana 2,539 26.7* AMI Medical Center of Garden Grove 409 26.4 Anaheim General Hospital 577 26.0 San Clemente General Hospital 643 25.5 Humana Hospital, West Anaheim 1,064 25.3 St. Joseph Hospital, Orange 4,454 25.3 Chapman General Hospital, Orange 1,040 23.8 Los Alamitos Medical Center 840 23.2 Fountain Valley Community Hospital 3,386 22.1 South Coast Medical Center, South Laguna 384 21.9 St. Jude Hospital, Fullerton 2,350 20.7 Humana Hospital, Westminster 2,000 20.3 Santa Ana Medical Center 972 18.7 UC Irvine Medical Center, Orange 3,347 17.7* Kaiser Foundation Hospital, Anaheim 2,482 16.8 SAN DIEGO COUNTY 36,729 20.2 Scripps Memorial Hospital, La Jolla 1,491 37.6 Sharp Memorial Hospital, San Diego 5,814 26.5 Fallbrook Hospital 713 24.3 Pomerado Hospital, Poway 917 20.9 Grossmont Hospital, La Mesa 2,980 20.2 Kaiser Foundation Hospital, San Diego 4,163 20.2 Tri City Hospital, Oceanside 1,913 20.1 Palomar Memorial Hospital, Escondido 1,873 19.8 Coronado Hospital 412 19.4 Paradise Valley Hospital, National City 782 19.4 Mercy Hospital & Medical Center, San Diego 2,648 19.3* Scripps Memorial Hospital, Chula Vista 2,501 19.2 UC San Diego Medical Center 3,116 19.0* Naval Regional Medical Center, Camp Pendleton 2,025 16.2 El Cajon Valley Hospital 189 15.3 Naval Regional Medical Center, San Diego 4,813 12.1

* indicates hospitals with level II (intermediate care) or level III (tertiary care) specialized neonatal nursery for high-risk babies. Such hospitals may, on average, have more reason to have high Caesarean-section rates than other hospitals because of the more severe medical conditions of some mothers and fetuses.

STATEWIDE CAESAREAN SECTIONS (BY HOSPITAL OWNERSHIP: 1984)

% Caesarean Sections Nonprofit hospitals 23.8 For-profit hospitals 23.6 District Hospitals 22.5 Kaiser Foundation Hospitals 17.9 UC Hospitals 17.7 Federal Hospitals 15.0 County Hospitals 14.2