Study Finds High Cesarean Birth Rate at Area Hospitals : Medicine: Critics say the incidence is because of financial incentives, a fear of malpractice suits and physicians’ haste to operate.
Hospitals in the San Fernando Valley have some of the highest rates of Cesarean-section births in the state and, contrary to the trend nationally, in some cases those figures have been rising, according to a new study.
Released last week by Public Citizen’s Health Research Group, the study showed that based on 1989 data, three local hospitals were in the top five in the state, delivering about four babies in 10 by Cesarean section.
Dr. Sidney M. Wolfe, director of the consumer advocate group, said he believes the appropriate Cesarean-section rate based on all factors is about 12%.
Despite a nationwide trend toward fewer deliveries by Cesarean section, the survey showed that rates for two of the four top-ranking Valley hospitals actually had gone up since a previous study three years earlier.
West Valley Hospital and Health Center in Canoga Park had the third-highest rate in the state at 40.4%. Northridge Hospital Medical Center was fourth at 39.3%; Valley Presbyterian Hospital in Van Nuys was fifth at 39.0%, and AMI Tarzana Regional Medical Center, was eighth at 37.6%. The state average is 22.9%.
Critics say high Cesarean rates are fueled by financial incentives, fear of malpractice suits and physicians being too hasty to operate.
The rates at the Valley hospitals “are totally outrageous. They’re an abuse against women,” said April Kubachka, president of the Los Angeles chapter of the International Cesarean Awareness Network. “I just feel they could be taking measures to reduce C-section rates.”
Representatives of the Valley hospitals said they have tried to make sure all Cesarean deliveries are appropriate. Several hold monthly peer review meetings to look over each one and issue warnings to physicians who perform too many.
Two of the hospitals, Northridge and West Valley, report they already have brought down their Cesarean rates. Northridge spokeswoman Leslie Wither said the rate dropped to 33% last year and is continuing to fall this year.
“The biggest change is that more physicians are offering VBACs to patients,” said Catherine Van Wert, manager of the obstetrics department there. The term VBAC is an acronym for vaginal birth after Cesarean and refers to patients who attempt to have a normal delivery after they have had one or more Cesareans.
Dr. Eugene R. Sollman, chief of obstetrics at West Valley, which in 1989 was the Nu-Med Regional Medical Center, estimated that the Cesarean rate has fallen by 10 to 15% recently.
Physicians with the other two hospitals acknowledged their Cesarean rates are high. “It should be brought down,” said Dr. Cameron Malek, chairman of the department of obstetrics and gynecology at Valley Presbyterian. “We are working to see what we can do.”
Malek and representatives of Tarzana Regional Medical Center said the reason for their rates is that they accept high-risk cases that are more likely to result in Cesarean sections to avoid injury to the mother or child.
But some hospitals with much lower rates also accept high-risk cases. Kaiser Foundation Hospital in Woodland Hills had a 16.4% Cesarean rate despite accepting such problematic cases.
There have been a number of reasons that have been advanced for the upsurge in cesareans that occurred in the United States after 1965, when the rate was just 4.5%. But several obstetricians said none of them satisfactorily explain the cluster of Valley hospitals with high rates.
The head of one obstetrics department in the Valley summed up the situation: “A lot of hospitals are doing lots of C-sections for lots of reasons.”
“I honestly can’t tell you why” the rate is higher in the Valley than in his Torrance practice, said Dr. Reinhold Ullrich. “Consumer advocates might say they’re more money-hungry in the Valley.”
Wolfe, of the consumer advocacy group, said two factors elevate Cesarean rates. One is the socioeconomic status of the area and the other is whether the hospital is a for-profit institution.
Wealthier women with better insurance coverage, such as many in the Valley, are more likely to have Cesareans, according to a study by the National Center for Health Statistics; in 1990, women with private insurance had a 26.1% Cesarean rate while self-paying women had a 16.6% rate.
Typical physician and hospital charges for a Cesarean section are $7,186, compared to $4,334 for a vaginal birth.
“The number one serious operation in the nation is the C-section,” said Wolfe, head of the consumer group. “We call these operations unnecessary, but the hospitals call them $3,000.”
Wolfe also said there is a statistically significant difference between for-profit hospitals and nonprofit facilities. With a third of the hospital beds around the country sitting empty there is pressure on for-profit hospitals to fill them, and a Cesarean results in a five-day hospital stay compared to a two-day stay for vaginal deliveries.
But the difference between for-profit and nonprofit institutions is not always clear. Cesarean rates at West Valley, for example, have fallen since it changed ownership and became a nonprofit hospital last year. But Northridge and Valley Presbyterian, which were ranked high in the health research group report, are both run as nonprofit institutions. Kaiser also is a nonprofit facility yet its Cesarean rate in 1989 was less than half that of the other facilities.
There are some significant differences between the operations at Kaiser and the other facilities. For example, obstetricians at Kaiser work 24-hour shifts in pairs. This means there is no impetus for them to hurry the delivery along for convenience, because their workday ends at the same time no matter what, doctors said.
Also, Kaiser physicians work on a contract basis with the Kaiser Permanente corporation, so they get no financial reward from performing Cesareans, said Dr. John Medders, assistant area medical director at the Kaiser facility in Woodland Hills.
When there is no financial gain to be made, the Cesarean rate drops, according to a 1990 study of the state’s Medi-Cal program published in the American Journal of Public Health. The state program, which serves poor women, pays doctors the same for delivering babies regardless of the method and the study found that Medi-Cal patients are less likely to have Cesareans.
Fear of malpractice lawsuits also may be a contributing factor to high Cesarean-section rates. “In areas of relative affluence, doctors practice defensive medicine” because they fear lawsuits, said David Langness, vice president of communications for the Hospital Council.
“If there is any indication, especially in a more affluent area, that the child is in distress and the birth is going to be difficult, the obstetrician is very quick to recommend a Cesarean section,” said Langness.
“We as a group are scared to death,” said Dr. Gary London, an obstetrician at Valley Presbyterian.
“No one gets sued for doing a C-section,” said West Valley’s Sollman. “You can get sued for millions if you don’t.”
Another factor is patient preference. Some women prefer not to go through the pain and inconvenience of a lengthy labor, said several obstetricians.
“There is enormous pressure from patients to do C-sections,” said London. “It’s not that we talk patients into doing them. Nobody likes labor. Nobody has ever said, ‘Gee, that was too short.’ ”
He said he doesn’t think the national rate will drop much below 30%, which is the percentage of deliveries he performs by Cesarean section.
Valley Presbyterian’s Malek said the Valley’s changing demographics may be having an impact on the Cesarean rate. Because of improved nutrition, women from other nations who come here are having larger babies, said Malek. While healthier, the size of these babies may make it difficult for the women to deliver vaginally, he said.
All or some of the above reasons have been cited for the Cesarean rate nationally. One study, however, found one factor possibly underlying all of them: the doctor.
A 1990 study based on a yearlong survey of a suburban Detroit hospital, and published in the New England Journal of Medicine, found “substantial variation in the rate of Cesarean section that appears to be attributable solely to differences among individual clinicians.”
In other words, each doctor had his or her own view about when Cesareans were appropriate. The study said, “this ‘physician factor’ in determining the method of delivery has previously been underappreciated or underreported.”
The four Valley hospitals denied letting the fear of lawsuits, or anything else except a desire to provide the best care possible, influence them. “We do not practice defensive medicine,” said Malek of Valley Presbyterian. “We practice defensible medicine. We do not alter health care because somebody might unjustifiably sue us one day.”
Concerning the role of the physician in the Cesarean rate, several said they review the performance of their doctors very aggressively. At West Valley, for instance, 16 obstetricians, pediatricians and anesthesiologists sit in on monthly meetings and go over every chart.
Sollman said no doctors had been barred from practicing there for performing too many Cesarean sections. “But if the rate is too high, it doesn’t stay high very long,” he said.
Almost all of the facilities said a major contributing factor to the Cesarean rate is the number of high-risk cases they accept.
“Because of our strong perinatal program, we see a heck of a lot of high-risk moms,” said Roger Drue, chief executive officer at AMI Tarzana. “When you do that, you will obviously see more C-sections.”
At Northridge, where the rate has dropped significantly since the 1989 figures, officials said that one reason is that more patients are better informed.
“The biggest thing is the change in the consumer,” said Van Wert. “I’ve heard from patients who say they called around looking for physicians willing to offer VBAC.”
Several experts agreed that allowing women who have had Cesareans to try to deliver vaginally is a way to significantly reduce the rate.
In 1990 at Northridge, one in six women who had had Cesarean sections were allowed to first try to deliver vaginally and 30 of 53 succeeded. So far this year, about one in four such women were allowed to try to deliver normally and 32 out of 49 succeeded.
But even this rate of VBACs hardly measures up to Kaiser’s performance. Medders estimated that 70% to 85% of Kaiser patients have successful vaginal deliveries after a Cesarean.
Some of the other hospitals worry about the danger of a ruptured uterus during a VBAC. The fear is that the wall of the uterus won’t be strong enough after having been cut once to withstand sustained labor. A rupture can be dangerous to the mother and child.
“Our criteria on VBACs are a little strict because we don’t want complications,” said Malek.
Dr. Bruce Flamm, a Kaiser physician in Riverside who has been critical of high Cesarean rates, said the argument that the uterus might rupture “has been used for decades to support automatic repeat Cesareans.” He said that, on the contrary, studies show VBAC is a safe procedure and that the mortality rates for such deliveries is no higher than for all deliveries.
Cesarean Rates
The top 10 Cesarean section rates among California hospitals in 1989, with area hospitals in bold (*):
Bakersfield Memorial Hospital: 41.9%
Circle City Hospital, Corona: 40.5%
* West Valley Hospital and Health Center, Canoga Park: 40.4%
* Northridge Hospital Medical Center: 39.3%
* Valley Presbyterian Hospital, Van Nuys: 39.0%
Wheeler Hospital, Gilroy: 38.6%
El Centro Regional Medical Center, San Diego: 37.7%
* AMI Tarzana Regional Medical Center: 37.6%
San Clemente General Hospital: 37.3%
Huntington Memorial Hospital, Pasadena: 36.9%
State average: 22.9%
Source: Public Citizen’s Health Research Group, based on state of California figures
