Cesarean Birth Rate Falling in U.S., Researchers Say : Medicine: Percentage in California is also lower. Health group says many of the surgeries are unnecessary.

The Cesarean birth rate in California and the nation dropped slightly between 1989 and 1990, reversing a steady increase in the rate of surgical deliveries over the previous quarter-century, according to a report released Tuesday.

But despite the favorable trend, the study by the Washington-based Public Citizen’s Health Research Group said that the rate of Cesarean sections is still nearly twice as high as it should be.

“We are optimistic that this important turnaround signals the beginning of the end of this national epidemic,” said Dr. Sidney M. Wolfe, the director of the consumer advocate group and one of the authors of the report.

Wolfe, who has crusaded against “unnecessary Cesareans” for many years, charged that nearly 500,000 unwarranted surgeries are performed each year, at an estimated cost of $1.3 billion. These operations “are a major example of violence against women,” he said.

The national Cesarean rate--the percentage of all deliveries performed by Cesarean section--increased from 4.5% in 1965 to 24.7% in 1988, according to federal statistics.

But between 1989 and 1990, the national rate declined, according to statistics cited in the report. Based on a sample of more than 2.5 million births each year, the rate decreased from 23% in 1989 to 22.7% in 1990, a significant difference. The 1989 and 1990 rates were based on a larger sample than previous years’ figures and thus are more reliable, according to the report.

California’s Cesarean section rate was 22.9% in 1989 and 21.4% in 1990--significant declines from the 24.5% recorded in 1986.

The study cites several explanations for the slight drop. They range from the growth of consumer activist groups, such as the Syracuse, N.Y.-based International Cesarean Awareness Network, publicity about the high Cesarean rates at individual hospitals, greater attention to the issue among obstetricians, and educational programs for physicians at individual hospitals, such as Kaiser Permanente facilities in Southern California.

In a few states, such as Massachusetts, hospitals must tell maternity patients the institution’s Cesarean rate, another possible reason for the downturn.

Another positive trend cited in the report is an increase in the percentage of vaginal births for women who have had children by Cesarean section. These cases, which account for more than one-third of all Cesareans, are the most common reason for the surgery.

Previously, the refusal of some obstetricians to consider a vaginal birth for such women fueled the growth of the surgeries. The national rate of vaginal birth after Cesareans increased from 12.6% in 1988 to 20.4% in 1990.

The report recommended that hospitals help to control the use of the surgeries through such steps as enforcing standards on their physicians and developing informational pamphlets for patients. It also supported the increased use of midwives in labor and delivery programs.

Cesarean section is the most common major operation in the United States. During the surgery, the abdomen and uterus are cut open to deliver the baby. The operation is essential in some instances to the health of the mother or the fetus, such as when the fetus has an abnormal heartbeat or when a vaginal birth is considered unsafe.

In recent years, there has been widespread concern that the operation is performed too frequently. Vaginal births are less than half as expensive as surgical deliveries and the mother’s recuperation is quicker. Women often leave the hospital within 24 hours of a vaginal birth; after a Cesarean section, mothers may may be hospitalized for three to four days.

Typical physician and hospital charges for a C-section are $7,186, compared to $4,334 for a vaginal birth. Only a handful of insurers, such as Blue Cross/Blue Shield programs in a few states, reimburse physicians at the same rate for vaginal and Cesarean deliveries, the report said.

Many leading obstetricians consider a desirable Cesarean rate to be between 15% and 20%, but the report suggests that 12% to 14% would be the proper rate. These estimates are based on medical studies and expert opinions about the percentage of women who require the surgery when given state-of-the-art care.

Kate Ruddon, a spokeswoman for the Washington-based American College of Obstetrics and Gynecology, said the college agreed that Cesarean section rates are “too high.”

But she said the organization, whose membership includes most practicing obstetricians, disagreed with the 12% goal cited in the report and the conclusion that nearly half of the operations are unnecessary. Ruddon said there were “too many variables” related to the types of patients at different hospitals to set a target national rate.

Using data collected from state health departments, the report includes Cesarean rates for 2,657 hospitals in 34 states, and overall figures for an additional 13 states and the District of Columbia.

The report’s list of 104 hospitals with the highest Cesarean section rates--37% and above--included 10 hospitals in California.

Bakersfield Memorial Hospital topped the California list at 41.2%. Tim Langeliers, the hospital’s director of marketing, attributed the rate to a high percentage of high-risk births. He said a nearby birthing center performed many of the normal deliveries in the area.

In California, 58 hospitals had Cesarean rates of 30% or more. Twenty-six hospitals, including Los Angeles County/USC Medical Center and UCLA Medical Center, had rates of 16% or less. Kaiser Foundation Hospitals had an overall rate of 18.3%.

Statewide rates in 1989 varied from a high of 31.7% in Nevada to a low of 15.2% in Alaska. The hospital with the highest Cesarean rate in the country was 57.5% at Abrom Kaplan Memorial Hospital in Kaplan, La. Eight of the top 14 hospitals on the list are in Louisiana.

Cesarean Section Rates

These are the highest and lowest Cesarean section rates in 1989 for hospitals in Los Angeles, Orange, San Diego and Ventura counties. The analysis, based on state statistics, was done by the Public Citizen’s Health Research Group. Only hospitals with more than 500 deliveries are listed.

TOTAL CESAREAN HOSPITAL DELIVERIES RATE (%) Highest Cesarean Section Rates *Nu-Med Regional Medical Center, Canoga Park 520 40.4 *Northridge Hospital Medical Center* 2,171 39.3 *Valley Presbyterian Hospital, Van Nuys 2,674 39.0 *AMI Tarzana Regional Medical Center 1,952 37.6 *San Clemente General Hospital 544 37.3 *Huntington Memorial Hospital, Pasadena* 5,146 36.9 *Los Angeles Community Hospital 996 36.7 *Charter Suburban Hospital, Paramount 1,287 35.7 *Glendora Community Hospital 857 35.6 *Bellwood General Hospital, Bellflower 597 35.5 *Scripps Memorial Hospital, La Jolla* 2,109 34.8 *Verdugo Hills Hospital, Glendale 1,288 34.5 *Medical Center of North Hollywood 577 34.3 *Los Robles Regional Medical Center, Thousand Oaks 1,272 34.0 *Westlake Community Hospital, Westlake Village 739 34.0 *Garfield Medical Center, Monterey Park* 3,443 33.4 *Queen of Angels/ Hollywood Presbyterian Medical Center 3,295 32.9 *Santa Monica Hospital Medical Center* 2,391 32.9 *West Covina Hospital 858 32.3 Lowest Cesarean Section Rates *L.A. County/Olive View Medical Center, Sylmar* 5,923 10.1 *Kaiser Foundation Hospital, Anaheim* 3,607 12.5 *L.A. County/USC Medical Center* 17,786 12.8 *Martin Luther King Jr./Drew Medical Center 8,395 13.2 *UCLA Medical Center* 2,601 14.0 *Harbor/UCLA Medical Center, Torrance* 8,059 14.5 *Kaiser Foundation Hospital, Los Angeles 4,574 15.7 *Medical Center of La Mirada 2,223 15.9 *UCI Irvine Medical Center, Orange* 6,044 16.3 *Kaiser Foundation Hospital, Woodland Hills* 1,992 16.4 *Kaiser Foundation Hospital, Harbor City* 2,394 16.7 *Santa Teresita Hospital, Duarte 1,123 17.4 *White Memorial Medical Center, Los Angeles* 5,101 17.5

* Indicates hospital with a neonatal intensive care unit.

Source: Public Citizen’s Health Research Group, “Unnecessary Cesarean Sections: Halting a National Epidemic,” Washington, D.C., 1992.

Compiled by Times researcher Tracy Thomas