Are California’s For-Profit Hospitals Pushing C-Sections?

Expectant mothers in California may want to add one more reminder to their list of what to look for when researching obstetricians–whether the physician in question facilitates births in a non-profit or for-profit hospital.

An analysis by California Watch reveals stark disparities in cesarean section rates between non- and for-profit hospitals in the state. Women in the state are, according to an article written about the newly released analysis, “at least 17 percent more likely to have a cesarean section at a for-profit hospital than at one that operates as a non-profit.” The analysis looked at both base rates for c-sections as well as rates among women with low-risk pregnancies.

The differences in c-section rates between certain non- and for-profit hospitals across the state are shocking. Laboring women with low-risk pregnancies at Kaiser Permanente Redwood City Medical Center, a nonprofit hospital, had a 14 percent chance of giving birth via cesarean section. If these same women were to give birth at the for-profit Los Angeles Community Hospital? The likelihood they’d undergo a c-section shoots up to 47 percent; 59 percent if, notes the article, you factor in medically necessary c-sections. 

Nationally, cesarean section births account for almost one-third of all births, far above the 10 to 15 percent the World Health Organization deems safe.

While some point to overall changes in maternity patient demographics (older mothers, more mothers pregnant with multiples) and increased maternal request as reasons for this rise, time and again the evidence does not seem to agree. Recently, research undertaken by an NIH organization found that rising rates of labor induction in hospitals around the country contribute to our escalating rate of c-sections. But why are women birthing in hospitals being steered towards more medical intervention if the evidence does not show that it’s needed? And how does this connect to whether a hospital operates as a non-profit or for-profit venture?

The analysis did include findings from interviews with health professionals that revealed that increasesd c-section rates at some hospitals were due to staffing schedules on the maternity ward and physicians’ “level of patience.” The report also found another thread: the profit incentive for performing cesarean sections. A c-section has the potential, notes the article, to bring in twice the revenue of a vaginal delivery.

According to the article,

In California, hospitals can increase their profits by 82 percent on average by converting a normal birth to a C-section, according to a 2007 analysis by the Pacific Business Group on Health.

The group – a coalition of business, education and government agencies – estimated that average hospital profits on an uncomplicated C-section were $2,240, while profits for a comparable vaginal birth were $1,230.

While many media reports tout the idea that mothers are clamoring for c-sections for the “convenience” factor, California Watch found that women are expressing frustration with the pressure to undergo potentially unnecessary interventions.

Rebecca Zavala, 29, a teacher and makeup artist in Ventura, said she felt pressured to have a C-section.

Zavala consented to have her delivery induced a week early because the baby’s head seemed large and because the doctor was about to leave for vacation.

Zavala went to the nonprofit Santa Monica-UCLA Medical Center, where nurses gave her drugs to dilate her cervix and start the contractions. After four hours, in which labor progressed slowly, Zavala’s doctor broke her water and turned up the drug, stimulating contractions.

Shortly thereafter, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed. Nurses congratulated Zavala on being an accommodating patient.

The hospital’s response to Zavala’s frustration was to claim that they abided by their own policy, to require “informed consent” from the mother prior to performing surgery. Zavala, however, says she didn’t understand the full range of consequences of a c-section when signing the agreement, and her doctor did not explain them to her.

Labor induction is medically indicated for certain reasons including: high blood pressure, diabetes, post-term pregnancy or an infection. The size of a baby’s head is not a medical reason to induce labor early. It is undoubtedly a woman’s choice whether or not to undergo a c-section. However, it’s critical that a woman understand the full range of risks associated with the surgery so that she can weigh them against the benefits.

Although Santa Monica-UCLA is a nonprofit hospital, they have one of the highest rates of c-sections in the state. Still, the four hospitals with the highest rates of low-risk c-sections in the state are for-profit, with c-section rates double that of most of the other hospitals. Seven out of the ten hospitals with the highest rates are also for-profit, while those with the lowest rates are non-profit.

The report also found that the four hospitals with the highest rates operated in the “poorer parts of Los Angeles County, where the numbers of African-American and Hispanic populations are above the state average.” African-American women have a higher rate of c-sections, across the country, than do White women. They are also four times more likely to die during childbirth.

It’s information like this which pushes the issue beyond statistics to matters of life and death.

While there is no clear answer, yet, over whether profit incentives are behind the c-section rate differential between for- and non-profit hospitals, some hospitals are taking action with positive results:

Riverside County Regional Medical Center in Moreno Valley has one of the lowest C-section rates at 9 percent.

Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional, attributes his hospital’s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.

“If I come in in the morning, look over the charts and see that one of the patients just had a C-section without medical indication,” Valenzuela said, “you can bet that I’m going to start asking questions.”

There is certainly a growing awareness coupled with concern that this country’s rising c-section rates do nothing to improve the health and well-being of mothers or newborns. Women should ultimately be the decision-makers when it comes to whether or not to undergo a c-section, regardless of the reason. However, there is cause for concern when a major surgical procedure is being performed for reasons less related to a woman’s decision than her physicians’ schedule. Recently an NIH Consensus Panel of maternal health experts held a conference on vaginal births after cesarean sections (VBACs). What came out of that series of meetings was a consenus statement that VBACs may be safer than repeat c-sections for women and so should be more widely accessible in hospitals around the country. ACOG recently revised its own policy on VBACs as well. The California Watch report also notes that:

“The Joint Commission, the nation’s top hospital accreditation organization…[announced] this year that it would begin using low-risk C-section rates to measure hospital quality.”

Finally, a growing body of evidence suggests that in order to truly fix our ailing maternity care system, we must address the payment structures and profit incentives for care that favor more easily controlled births using interventions like artificial labor induction and c-sections over allowing a trial of labor and vaginal delivery.

The California Watch report provides an opportunity to ask: Why are pregnant and laboring women in the United States undergoing higher-than-ever rates of medical intervention, without clear, medical reasons to do so? If, as the article suggests, much of this boils down to financial incentive for hospitals, the answer is not only systemic reform but the push for more and better education and awareness among women that the hospital in which they choose to give birth may strongly determine how they give birth, no matter their own preferences.

For more information or to read the analysis and corresponding statistics, visit California Watch.

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  • amytuteurmd

    This study shows exactly the opposite of what Johnson claims. The association between the status of hospitals and their C-section rates is so weak as to demonstrate that there is no connection at all.

    Take smoking and lung cancer, for example. Smoking increases the risk of lung cancer by more than 2000%. How about homebirths? Homebirth advocates are fond of claiming that the increased risk of neonatal death at homebirth is trivial, but CDC statistics indicate that it is in the range of 200%. In contrast, a 17% increase in C-section rate between for profit and not for profit hospitals is so small as to indicate that there is no relationship at all.

    And that doesn’t even address the fundamental flaws in the actual analysis. First, the risk status of patients in hospitals may differ between for profit and not for profit hospitals in ways that were not taken into account in the analysis. Second, Johnson himself found that there was no correlation between the volume of high paying vs. low paying patients and the C-section rate. If profit were driving an increased C-section rate, hospitals that have more indigent and non-paying patients should have lower C-section rates, but they do not. Third, and perhaps most important, Johnson did not demonstrate any connection between the profit status of the hospital and the profitability of C-sections. His entire analysis rests on the assumption that hospitals make more money for C-sections, but there is no set rate for reimbursement for obstetric care. Hospitals make contracts with individual insurers that provide different compensation for the same procedures. Depending on the specific contracts, C-sections might be profitable if the patient carries insurance from Company A, but unprofitable if the patient carries insurance from Company B. Profitability depends entirely on whether the compensation for the procedure defrays the costs incurred for that procedure. Depending on the specific reimbursement rate, a C-section could actually be less profitable than a vaginal delivery, because a C-section requires far more resources.

    The bottom line is this: California Watch did NOT demonstrate an association between profit status and C-section rates. In fact, Nathanael Johnson’s analysis for California hospital C-section rates demonstrates exactly the opposite. A 17% increase in C-sections is so small as to be meaningless. In other words, Johnson demonstrated that there is NO association between profit status and C-section rate.

  • julie-watkins

    Two times a small number is still a small number! That hasn’t changed.

    Homebirth advocates are fond of claiming that the increased risk of neonatal death at homebirth is trivial, but CDC statistics indicate that it is in the range of 200%. In contrast, a 17% increase in C-section rate between for profit and not for profit hospitals is so small as to indicate that there is no relationship at all.

    Apples & spinach. If someting happens infrienquently, doubling the risk means it might happen 2 in 100 times instead of 1 in 100 times. If a 17% increase of cesareans vs vaginal births — since it’s only one or the other — then it’s (for instance) 35 cesareans instead of 30, when the optimal is 15 per hundred? Am I remembering right? Anyway, you’re equating two different types of measures just casts doubt on the rest of your analysis.

    You’re so hungup on homebirths that you’ll bring it up at any excuse. Funny. So, now I get to point this out again: If, ballpark, a normal hospital birth is $15 K — or $40 K if the doctors decide on a cesarean (and the evidence seems to be there are many unnessary ceseareans) and if a homebirth midwife is $6 K (and her record is very good outcomes & few referrals to the local hospital), and if $15 K will risk lossing your home & $40K will make homelessness a certainty, then it’s logical for a pregnant woman to plan for a homebirth. IE, if the risk of bad complication is 1% (& I think it’s less than that) & the risk of becoming homless is 20%-100% (ie: 1 in 100 vs. 1 in 5 or 1 in 1 (for certain)), attempted homebirth is logical.