‘Runaway’ C-Section Rates Reflect ‘Crisis’

Nearly one-quarter of California hospitals with more than 100 deliveries had Caesarean birth rates of 30% or more in 1986--nearly double the 15% to 20% range that many leading obstetricians consider desirable, according to a Times analysis of data covering nearly all births in the state.

Such “runaway” Caesarean section rates are a “major crisis” and “represent an enormous drain on our private and public health care budgets,” said Dr. John T. Queenan, chairman of obstetrics at Georgetown University School of Medicine in Washington and the editor of the journal Contemporary Ob/Gyn.

The escalating Caesarean rate is fueled by such factors as inadequate attempts by physicians at vaginal deliveries, financial incentives and, according to some obstetricians, by the fear of malpractice suits.

Suit Nearly Certain

When a baby has a “bad outcome” and a Caesarean section was not performed, “an obstetrician is reasonably certain of being sued,” said Dr. Roger K. Freeman of Memorial Hospital Medical Center in Long Beach. Freeman, the medical director of Memorial’s Women’s Hospital, maintained that such a suit was likely irrespective of whether the method of delivery had anything to do with the baby’s problem.

In total, 41 Southern California hospitals had Caesarean rates of 30% or more in 1986, compared to 18 hospitals with such high rates in 1984. Officials at some of these hospitals were contacted by The Times; most acknowledged that their rates are excessive, but they said it is unrealistic to expect their rates to decrease substantially.

The hospitals with the highest rates included AMI Tarzana Regional Medical Center, Northridge Hospital Medical Center, Huntington Memorial Hospital in Pasadena and 21 others in Los Angeles County. They also included 11 institutions in Orange County, Scripps Memorial Hospital in La Jolla, San Bernardino Community Hospital and Sharp Memorial Hospital in San Diego.

Lower Rates in Some

By comparison, 16 Southern California hospitals had Caesarean section rates of 20% or less. They included UCLA Medical Center, Los Angeles County-USC Medical Center, UC Irvine Medical Center in Orange and five Kaiser Foundation Hospitals.

The national Caesarean rate has increased steadily over the last two decades--from 5.5% in 1970 to 16.5% in 1980 and 24.1% in 1986. The statewide rate, which stood at 24.5% in 1986, has followed a similar pattern.

According to current federal projections, the national Caesarean rate may top 40% by the year 2000. The procedure, the most common major operation in the United States, is performed nearly a million times each year.

“Certain high-risk patient populations require higher rates, but we see these high rates even in community hospitals, which care primarily for low-risk patients,” Queenan said in a symposium on the subject that was published in Contemporary Ob/Gyn last month. “No matter what the ideal rate may be, the actual rate is far higher today.”

Sharp Debate Under Way

The seemingly inexorable rise in Caesarean rates has triggered sharp debate about the need for corrective measures. The suggested remedies include audits of obstetricians with high rates, second opinions for elective Caesareans and the elimination of financial incentives that encourage surgical deliveries. Last year, for instance, Blue Shield of California decided to equalize the physician fees for Caesarean and vaginal deliveries, but it has yet to do so because of difficulty deciding what the appropriate fee should be. Currently, physicians usually receive significantly more money for surgical deliveries. The average physician’s charges for a Caesarean section in California in 1986 was $2,850, according to a recent study by Metropolitan Co.

In addition, leading obstetricians say that the majority of women with previous Caesarean sections can safely deliver vaginally--although fewer than 10% of such women nationwide now do so. Routine repeat sections account for one-third of all Caesareans nationwide and are considered the biggest single obstacle to bringing the rates under control.

“If a hospital is not ready to (offer) a trial of labor to a women with a previous Caesarean section, then it is not equipped to handle obstetrics at all,” said Dr. Bruce Flamm, an obstetrician at the Kaiser Foundation Hospital in Anaheim.

Authored a Study

Flamm is the principal author of a study of 1,776 California women with prior Caesareans that he published in the American Journal of Obstetrics and Gynecology in May. The study showed that 74% of the women successfully delivered vaginally after trying labor and supported the greatly expanded use of vaginal births after prior Caesareans.

During a Caesarean section, the abdomen and uterus are cut open to deliver the baby. The operation got its name from the ancient story that the Roman Emperor Julius Caesar or an ancestor had been born in this manner.

Though considered extremely safe operations, Caesarean deliveries generally pose slightly greater medical risks for mothers than vaginal deliveries. Vaginal births are less than half as expensive as surgical deliveries and the mother’s recuperation is quicker.

In most situations, Caesarean and vaginal deliveries are equally safe for the baby. In some situations, however, a Caesarean delivery may be safer for the baby. It can be done quickly, while a vaginal delivery may take hours.

Variety of Examinations

Good obstetrical practice involves the use of examinations, blood tests and medical technology to identify when Caesareans are necessary to safeguard the mother’s or baby’s health, such as when the fetus has an abnormal heartbeat or when there is a true inability to deliver a baby through the vagina. Two concerns are that some physicians may not make an adequate attempt to deliver babies vaginally or that they may misinterpret information from fetal monitors and perform unnecessary Caesarean sections as a result.

Patient preferences also play a role in the decision, but these preferences are usually influenced by the enthusiasm with which the doctor presents the various delivery options.

The Times analysis included 113,190 Caesarean sections and 461,142 total deliveries in 1986, the most recent year for which California birth statistics are available. It was based on computer tapes compiled by the Office of Statewide Health Planning and Development. The data is supplied and verified by individual hospitals and is considered highly accurate; in addition, The Times spot-checked the data of about 20 hospitals.

(The Times published a similar analysis of 1984 data in November, 1987, based on statistics compiled by the Community and Organization Research Institute at UC Santa Barbara.)

Highest Percentage

AMI Tarzana Regional Medical Center had the highest Caesarean section rate in California, 39.2% of 2,039 total deliveries. In 1984, it had the highest rate in Southern California.

Dr. Barry Schiffrin, the hospital’s director of maternal-fetal medicine, acknowledged that the 39.2% rate was “probably too high.” He said that the hospital had tightened its “peer review” procedures and that several physicians with “extraordinarily high section rates” were no longer practicing at the hospital. For the first six months of 1988, the Caesarean rate at the hospital was about 36%, he said.

“Every Caesarean section is reviewed,” Schiffrin said. “Everybody (is given) their exact Caesarean section rate to the decimal point.”

Schiffrin also acknowledged that “very few” patients at the hospital currently had vaginal births after Caesareans. He said a higher percentage of such births “would be desirable” but maintained that accomplishing this goal would require major changes in the way medicine is practiced at the hospital.

Four other private hospitals in the San Fernando Valley also had Caesarean rates of 34% or more. One was Northridge Hospital Medical Center, which had a 37.1% rate.

Demand for Perfection

Dr. Gary Feldman, chief of obstetrics at Northridge, said that a section rate lower than 25% to 30% is not a realistic goal for the hospital. Private patients are more likely than clinic patients--those patients who do not have personal physicians--to “demand perfect outcomes,” he said. “I think there are a lot of sections being done because of pressures on the physician. . . . With anything less than a perfect outcome, you are apt to have medical-legal problems.”

Another large community hospital with a high rate was Huntington Memorial Hospital in Pasadena. It had a 37% section rate.

“We have generally been scoring very high,” said Dr. Warren Nagata, an obstetrician who is chairman of Huntington’s obstetrics and gynecology quality audit subcommittee. “There are certain individuals on the staff whose personal rates may run as high as 60%.”

Nagata declined to characterize unusually high Caesarean rates as “good or bad,” saying that they had to be interpreted in light of the “outcome” for the mother and baby. But he acknowledged that the audit committee, which has not reviewed individual physicians’ Caesarean rates in the past, “will likely be doing this in the future.”

San Diego Figures

Scripps Memorial Hospital in La Jolla had the highest Caesarean rate in San Diego County, 37.9%. Dr. Donald J. Moore, chairman of the department of obstetrics and gynecology since 1987, said it would be difficult to lower the rate because “we are dealing with high-risk obstetrical referrals and career-oriented women who are having children at older ages.”

The mammoth Los Angeles County-USC Medical Center had the lowest Caesarean section rate in Southern California in 1986, at 13.6% of 16,910 total deliveries. The rate has now increased to about 18%, according to Dr. Richard H. Paul, director of maternal-fetal medicine at Women’s Hospital, because of a policy of referring many low-risk mothers to other hospitals.

The high volume of births at County-USC also means that physicians “cannot do all the Caesarean sections we would normally choose to do,” Paul said. Dozens of women are often in labor simultaneously.

Low at Kaiser

Another hospital with a low Caesarean rate is the Kaiser Foundation Hospital in Anaheim--in 1986, 14.5% of 2,786 total deliveries.

For the first six months of 1988, the hospital’s section rate was 13.3%, according to Kaiser statistics. Since 1980, the annual rate has never been higher than 16.6%.

The low rates reflect an emphasis on vaginal births after Caesarean and adequate attempts at vaginal birth for most babies, according to Flamm. The patients are comparable to those in many private hospitals, where the section rates are much higher.

“There is no magic in our statistics,” Flamm said. For example, in the first six months of 1988, 90 women with previous Caesarean sections had vaginal births out of 130 for whom such deliveries were attempted. If these deliveries had not been attempted, Flamm said the hospital’s Caesarean rate would have been about 50% higher.

According to Flamm, many obstetricians and patients have been reluctant to attempt a vaginal birth after a Caesarean because of a mistaken belief that “the uterus might explode and the baby might die.” In reality, this potential complication has been significantly reduced by the widespread use of a “low transverse” surgical incision that is not as prone to rupture, he said.

Other Problems

Some life-threatening obstetrical emergencies occur more frequently than uterine ruptures. Because hospitals where babies are delivered must be able to handle many types of emergencies, Flamm and others believe that patients attempting vaginal delivery after Caesarean are at no greater risk than other women in routine labor. The criteria for vaginal birth after Caesarean today “are virtually identical with those for any woman in active labor,” according to Memorial’s Freeman. “It must be possible to do a Caesarean within 30 minutes.” The attending physician must be “readily available” but “need not be at the bedside.”

The Times analysis also highlighted the differing financial and life style incentives to perform Caesarean sections for obstetricians in private practice and those who are not.

Kaiser obstetricians, for example, work for a health maintenance organization. They typically care for obstetric patients during 12- to 24-hour shifts. Their salaries are not dependent on the number of deliveries or the number of Caesareans. Similar situations are common at public hospitals and teaching hospitals.

By comparison, private obstetricians are usually paid substantially more for Caesarean deliveries, which take less than an hour, than for vaginal deliveries, which on occasion require the physician to sit with the patient for many hours. Private physicians attending to one of their patients in labor may have to stay up all night or to cancel scheduled appointments for other patients.

“Doctors are people, like plumbers,” Flamm said. “Nobody wants to do more work for less money at 3 in the morning.”

Different Doctor Groups

Similar differences in Caesarean rates have been observed between different groups of physicians at Memorial Hospital Medical Center in Long Beach, where large numbers of high-risk patients are cared for. Memorial had an overall 29.7% Caesarean section rate in 1986.

“The clinic service deals with a much higher-risk group than does the private practice, but its overall (Caesarean) rate is roughly half that of the private practice,” Freeman said in the Contemporary Ob/Gyn symposium. Memorial’s section rate for the highest-risk group of patients--those sent from other hospitals--was “only moderately higher” than for the private patients.

In an interview, Freeman acknowledged that Memorial physicians “could probably get away without doing . . . a lot of sections” but declined to fault colleagues with high Caesarean rates because of the “(medical-legal) environment we are in.”

The Times analysis also found:

- The percentage of Caesarean sections in California increased from 22.6% to 24.5% between 1984 and 1986. In 1986, there were 296 California hospitals with more than 100 deliveries; 72 hospitals, or 24.3%, had Caesarean rates of 30% or more; 64 hospitals, or 21.6%, had section rates of 20% or less.

- In Los Angeles, Orange, Riverside, San Diego, San Bernardino and Ventura counties, there were 140 hospitals with more than 400 deliveries in 1986; 41 hospitals, or 29.3%, had Caesarean rates of 30% or more; 21 hospitals, or 15%, had section rates of 20% or less.

- Elsewhere in the state, the hospitals with the highest Caesarean rates included El Centro Regional Medical Center (38.2%), Tulare District Hospital (38.5%), and Mercy Medical Center in Redding (36.4%).

- There were 162,871 deliveries in Los Angeles County and an overall Caesarean rate of 24.8%. The rate was 14.6% for 31,643 deliveries in county hospitals, 20% for 16,347 deliveries in six Kaiser hospitals and 28.3% for deliveries in all other hospitals.

- There are no current guidelines from leading professional groups, such as the American College of Obstetrics and Gynecology, defining proper Caesarean section rates for different risk groups of obstetrical patients. But most leading obstetricians contacted by The Times, as well as the physicians included in the Contemporary Ob/Gyn symposium, said a desirable range for most hospitals was between 15% and 20%.

These physicians included Queenan, Flamm, Freeman, Dr. Timothy R.B. Johnson of Johns Hopkins University, Dr. Edward J. Quilligan, dean of the UC Irvine School of Medicine and Dr. Jeffrey P. Phelan of Queen of the Valley Hospital in West Covina and Pomona Valley Community Hospital.

Times systems analyst Detlef D. Matthies did the computer programming for this story. Times researcher Tracy Thomas assisted in preparing the story.

CAESAREAN RATES The increasing Caesarean section rate in the United States, by percentage of deliveries: 1965--4.5% 1970--5.5% 1975--10.4% 1980--16.5% 1983--20.3% 1984--21.1% 1985--22.7% 1986--24.1% 0%510152025 U.S. Nat’l Center for Health Statistics CAESAREAN SECTION RATES IN SOUTHERN CALIFORNIA HOSPITALS--1986 These are the Caesarean section rates for Southern California hospitals with more than 400 deliveries in 1986, the most recent year for which statewide data is available. The statistics are based on a Times analysis of computer tapes compiled by the Office of Statewide Health Planning and Development.

STATEWIDE 461,142 LOS ANGELES COUNTY 162,871 AMI Tarzana Regional Medical Center* 2,039 Northridge Hospital Medical Center, Northridge 2,452 Huntington Memorial Hospital, Pasadena* 3,702 Humana Hospital: West Hills, Canoga Park 1,100 Verdugo Hills Hospital, Glendale* 931 West Covina Hospital 685 Valley Presbyterian Hospital, Van Nuys* 2,679 Torrance Memorial Hospital Medical Center* 2,312 St. Joseph Medical Center, Burbank* 2,217 Methodist Hospital of Southern California, Arcadia* 966 Foothill Presbyterian Hospital, Glendora 538 Brotman Medical Center, Culver City 645 Bay Harbor Hospital, Harbor City* 798 Inter-Community Medical Center, Covina* 554 Santa Monica Hospital Medical Center* 1,899 South Bay Hospital, Redondo Beach 1,692 Hollywood Presbyterian Medical Center 2,531 Bellwood General Hospital, Bellflower 573 Charter Suburban Hospital, Paramount 965 Presbyterian Intercommunity Hospital, Whittier 2,002 Beverly Hospital, Montebello 1,629 Glendale Memorial Hospital of Glendale* 611 Garfield Medical Center, Monterey Park 2,847 Queen of Angels Medical Center, Los Angeles 1,993 AMI San Dimas Community Hospital 789 Memorial Hospital Medical Center, Long Beach 5,338 St. John’s Hospital and Health Center, Santa Monica 1,657 Monterey Park Hospital 1,047 San Pedro Peninsula Hospital 803 Westlake Community Hospital, Westlake Village 633 Holy Cross Hospital, Mission Hills 2,466 Little Company of Mary Hospital, Torrance 2,159 Queen of the Valley Hospital, West Covina 3,939 California Hospital Medical Center, Los Angeles 2,857 Greater El Monte Community Hospital 1,054 AMI Glendora Community Hospital 816 Los Angeles Community Hospital 739 Henry Mayo Newhall Memorial Hospital, Valencia 1,008 Glendale Adventist Medical Center 2,270 Cedars Sinai Medical Center 6,639 Pioneer Hospital, Artesia 1,330 Mission Hospital, Huntington Park 1,627 St. Mary Medical Center, Long Beach 2.076 Granada Hills Community Hospital 1,209 St. Francis Medical Center, Lynwood 1,801 French Hospital of Los Angeles 1,169 East Los Angeles Doctors Hospital 633 Centinela Hospital Medical Center, Inglewood 1,700 Kaiser Foundation Hospital, Bellflower 4,570 Pomona Valley Community Hospital 2,965 Memorial Hospital of Gardena 928 Lincoln Hospital, Los Angeles 528 Doctors Hospital of Lakewood 856 Antelope Valley Hospital Medical Center, Lancaster 2,374 Santa Teresita Hospital, Duarte 628 Serra Memorial Health Center, Sun Valley 1,227 Dominquez Medical Center, Long Beach 1,220 Santa Marta Hospital, Los Angeles 1,589 Long Beach Community Hospital 2,293 Whittier Hospital 2,258 Kaiser Foundation Hospital, Woodland Hills 808 Kaiser Foundation Hospital, West Los Angeles 2,239 Memorial Hospital of Hawthorne 575 Rio Hondo Memorial Hospital, Downey 562 Kaiser Foundation Hospital, Panorama City 2,391 Pacific Hospital of Long Beach 522 Downey Community Hospital 674 UCLA Medical Center, Westwood 2,718 Kaiser Foundation Hospital, Harbor City 2,047 Kaiser Foundation Hospital, Los Angeles 4,292 Harbor UCLA Medical Center, Torrance 6,438 Medical Center of La Mirada 1,899 Valley Hospital Medical Center, Van Nuys 414 White Memorial Medical Center, Los Angeles 4,646 Martin Luther King, Jr. Medical Center 8,115 County-USC Medical Center 16,910 ORANGE COUNTY 38,741 Anaheim General Hospital 429 Humana Hospital Huntington Beach* 581 Coastal Communities Hospital, Santa Ana* 1,410 Mission Community Hospital, Mission Viejo 2,185 San Clemente General Hospital 582 Chapman General Hospital, Orange 1,084 La Palma Intercommunity Hospital 436 Humana Hospital West Anaheim 944 Martin Luther Hospital Medical Center, Anaheim 2,525 AMI Medical Center of Garden Grove 583 Western Medical Center, Santa Ana 2,144 Hoag Memorial Hospital Presbyterian, Newport Beach 2,321 St. Joseph Hospital, Orange 5.262 Los Alamitos Medical Center 892 South Coast Medical Center, South Laguna 450 Fountain Valley Community Hospital 3,973 St. Jude Hospital, Yorba Linda 602 FHP Hospital, Fountain Valley 1,748 St. Jude Hospital, Fullerton 1,631 Humana Hospital Westminster 721 Santa Ana Medical Center 1,099 UC Irvine Medical Center, Orange 4,024 Kaiser Foundation Hospital, AnaHeim 2,786 RIVERSIDE COUNTY 12,419 Circle City Hospital, Corona* 617 Corona Community Hospital* 915 Hemet Valley Hospital District, Hemet 980 Parkview Community Hospital, Riverside 1274 Riverside Community Hospital 1935 Desert Hospital, Palm Springs 1873 John F. Kennedy Memorial Hospital, Indio 1553 Riverside General Hospital 2536 SAN BERNARDINO COUNTY 19,813 San Bernardino Community Hospital* 1460 San Antonio Community Hospital, Upland 2556 St. Bernardine Hospital, San Bernardino 2152 Victor Valley Community Hospital, Victorville 580 Barstow Community Hospital 471 Doctors Hospital of Montclair 1958 Loma Linda University Medical Center 1900 Redlands Community Hospital 1636 Kaiser Foundation Hospital, Fontana 3661 St. Mary Desert Valley Hospital, Apple Valley 1310 San Bernardino County Medical Center 1740 SAN DIEGO COUNTY 35,777 Scripps Memorial Hospital, La Jolla* 1,664 Sharp Memorial Hospital, San Diego 6,694 Mercy Hospital & Medical Center, San Diego 3,351 Fallbrook Hospital 884 Coronado Hospital 754 Palomar Memorial Hospital, Escondido 1,963 UC San Diego Medical Center 3,514 Pomerado Hospital, Poway 1,172 Tri City Hospital, Oceanside 3,275 Grossmont Hospital, La Mesa 3,460 Kaiser Foundation Hospital, San Diego 4,308 Paradise Valley Hospital, National City 1,147 Scripps Memorial Hospital, Chula Vista 3,391 VENTURA COUNTY 8,908 Los Robles Regional Medical Center, Thousand Oaks 1207 Simi Valley Adventist Hospital 639 St Johns Regional Medical Center, Oxnard 1827 Community Mem. Hospital of San Buenaventura 1473 Ventura County Medical Center, Ventura 2516 Pleasant Valley Hospital, Camarillo 587

STATEWIDE 24.5% LOS ANGELES COUNTY 24.8% AMI Tarzana Regional Medical Center* 39.2 Northridge Hospital Medical Center, Northridge 37.1 Huntington Memorial Hospital, Pasadena* 37.0 Humana Hospital: West Hills, Canoga Park 36.5 Verdugo Hills Hospital, Glendale* 36.2 West Covina Hospital 35.9 Valley Presbyterian Hospital, Van Nuys* 34.9 Torrance Memorial Hospital Medical Center* 34.3 St. Joseph Medical Center, Burbank* 34.2 Methodist Hospital of Southern California, Arcadia* 34.1 Foothill Presbyterian Hospital, Glendora 34.0 Brotman Medical Center, Culver City 33.8 Bay Harbor Hospital, Harbor City* 33.7 Inter-Community Medical Center, Covina* 33.0 Santa Monica Hospital Medical Center* 33.0 South Bay Hospital, Redondo Beach 32.4 Hollywood Presbyterian Medical Center 32.3 Bellwood General Hospital, Bellflower 31.9 Charter Suburban Hospital, Paramount 31.8 Presbyterian Intercommunity Hospital, Whittier 31.8 Beverly Hospital, Montebello 31.7 Glendale Memorial Hospital of Glendale* 31.4 Garfield Medical Center, Monterey Park 31.2 Queen of Angels Medical Center, Los Angeles 30.4 AMI San Dimas Community Hospital 29.8 Memorial Hospital Medical Center, Long Beach 29.7 St. John’s Hospital and Health Center, Santa Monica 29.6 Monterey Park Hospital 29.4 San Pedro Peninsula Hospital 29.1 Westlake Community Hospital, Westlake Village 29.1 Holy Cross Hospital, Mission Hills 29.0 Little Company of Mary Hospital, Torrance 28.9 Queen of the Valley Hospital, West Covina 28.9 California Hospital Medical Center, Los Angeles 28.7 Greater El Monte Community Hospital 28.5 AMI Glendora Community Hospital 28.4 Los Angeles Community Hospital 28.3 Henry Mayo Newhall Memorial Hospital, Valencia 27.9 Glendale Adventist Medical Center 27.8 Cedars Sinai Medical Center 27.5 Pioneer Hospital, Artesia 27.3 Mission Hospital, Huntington Park 27.2 St. Mary Medical Center, Long Beach 27.2 Granada Hills Community Hospital 27.1 St. Francis Medical Center, Lynwood 26.7 French Hospital of Los Angeles 25.8 East Los Angeles Doctors Hospital 25.4 Centinela Hospital Medical Center, Inglewood 24.4 Kaiser Foundation Hospital, Bellflower 24.2 Pomona Valley Community Hospital 23.8 Memorial Hospital of Gardena 23.7 Lincoln Hospital, Los Angeles 23.5 Doctors Hospital of Lakewood 23.4 Antelope Valley Hospital Medical Center, Lancaster 23.3 Santa Teresita Hospital, Duarte 23.2 Serra Memorial Health Center, Sun Valley 23.2 Dominquez Medical Center, Long Beach 22.3 Santa Marta Hospital, Los Angeles 22.0 Long Beach Community Hospital 21.2 Whittier Hospital 21.0 Kaiser Foundation Hospital, Woodland Hills 20.8 Kaiser Foundation Hospital, West Los Angeles 20.3 Memorial Hospital of Hawthorne 20.3 Rio Hondo Memorial Hospital, Downey 20.3 Kaiser Foundation Hospital, Panorama City 20.0 Pacific Hospital of Long Beach 19.2 Downey Community Hospital 18.7 UCLA Medical Center, Westwood 18.2 Kaiser Foundation Hospital, Harbor City 17.4 Kaiser Foundation Hospital, Los Angeles 16.8 Harbor UCLA Medical Center, Torrance 16.2 Medical Center of La Mirada 15.9 Valley Hospital Medical Center, Van Nuys 15.7 White Memorial Medical Center, Los Angeles 15.4 Martin Luther King, Jr. Medical Center 15.3 County-USC Medical Center 13.6 ORANGE COUNTY 26.0% Anaheim General Hospital 36.6 Humana Hospital Huntington Beach* 35.6 Coastal Communities Hospital, Santa Ana* 35.2 Mission Community Hospital, Mission Viejo 34.1 San Clemente General Hospital 33.2 Chapman General Hospital, Orange 32.1 La Palma Intercommunity Hospital 32.1 Humana Hospital West Anaheim 32.0 Martin Luther Hospital Medical Center, Anaheim 31.6 AMI Medical Center of Garden Grove 31.0 Western Medical Center, Santa Ana 30.8 Hoag Memorial Hospital Presbyterian, Newport Beach 29.6 St. Joseph Hospital, Orange 28.8 Los Alamitos Medical Center 26.9 South Coast Medical Center, South Laguna 26.4 Fountain Valley Community Hospital 25.8 St. Jude Hospital, Yorba Linda 25.1 FHP Hospital, Fountain Valley 24.5 St. Jude Hospital, Fullerton 23.5 Humana Hospital Westminster 23.2 Santa Ana Medical Center 21.0 UC Irvine Medical Center, Orange 18.4 Kaiser Foundation Hospital, AnaHeim 14.5 RIVERSIDE COUNTY 24.8% Circle City Hospital, Corona* 37.0 Corona Community Hospital* 31.9 Hemet Valley Hospital District, Hemet 29.3 Parkview Community Hospital, Riverside 28.3 Riverside Community Hospital 27.2 Desert Hospital, Palm Springs 25.6 John F. Kennedy Memorial Hospital, Indio 23.1 Riverside General Hospital 15.3 SAN BERNARDINO COUNTY 24.6% San Bernardino Community Hospital* 35.3 San Antonio Community Hospital, Upland 29.3 St. Bernardine Hospital, San Bernardino 28.3 Victor Valley Community Hospital, Victorville 28.1 Barstow Community Hospital 28.0 Doctors Hospital of Montclair 26.1 Loma Linda University Medical Center 25.4 Redlands Community Hospital 21.4 Kaiser Foundation Hospital, Fontana 21.0 St. Mary Desert Valley Hospital, Apple Valley 19.5 San Bernardino County Medical Center 14.5 SAN DIEGO COUNTY 25.3% Scripps Memorial Hospital, La Jolla* 37.9 Sharp Memorial Hospital, San Diego 30.2 Mercy Hospital & Medical Center, San Diego 27.9 Fallbrook Hospital 27.3 Coronado Hospital 25.5 Palomar Memorial Hospital, Escondido 23.9 UC San Diego Medical Center 23.8 Pomerado Hospital, Poway 23.2 Tri City Hospital, Oceanside 23.1 Grossmont Hospital, La Mesa 22.7 Kaiser Foundation Hospital, San Diego 21.9 Paradise Valley Hospital, National City 20.7 Scripps Memorial Hospital, Chula Vista 20.6 VENTURA COUNTY 24.9% Los Robles Regional Medical Center, Thousand Oaks 32.6 Simi Valley Adventist Hospital 29.3 St Johns Regional Medical Center, Oxnard 25.1 Community Mem. Hospital of San Buenaventura 25.7 Ventura County Medical Center, Ventura 22.0 Pleasant Valley Hospital, Camarillo 20.4

* Indicates hospitals that also had Caesarean section rates of 30% or more in 1984.