Thirty-four percent of single-baby births in 2009 were done surgically, the highest percentage ever.
The study – based on data from 19 states, including California – reflects the growing popularity of C-sections, whose use increased by more than 50 percent from 1996 to 2007. The study also rates individual hospital performance based on maternal care and gynecologic surgery.
California ranked eighth among the 19 states in the rate of C-section use, at 32.82 percent.
"This is a big issue, and this is actually going to come under a lot of scrutiny in the coming year," said Dr. Elliott Main, chairman of the Department of Obstetrics and Gynecology at California Pacific Medical Center in San Francisco. "A lot of organizations and bodies are going to start paying a lot more attention."
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While C-sections most often are used when complications arise during labor, the study says changing physician practices, such as inducing labor and a desire by physicians and patients to schedule convenient times for labor, may be leading to the increase. Risk factors that could lead to necessary C-sections – including obesity, diabetes, multiple births and older pregnant women – also are more common, though Main says they account for only a small portion of the increase.
"It's more an attitudinal issue of doctors and patients not wanting to spend extra time in labor or not wanting to take any perceived extra risk," he said.
According to quality measures set out by The Joint Commission, a leading health care accreditation group, no data exists to show “that higher rates improve any outcomes, yet the C-section rates continue to rise.”
Main echoed that idea.
"At the end of the day, the C-section rate has risen ... over the past decade, and we don't have any improved baby outcomes to show for it, so there is a big question of what we are getting for our money," he said.
In fact, hemorrhaging from C-sections is one of several possible factors in the state’s increased maternal death rate, the subject of a California Watch report last year. The number of women in California who died from pregnancy-related complications rose from 5.6 out of 100,000 live births in 1996 to 14 out of 100,000 in 2008. Only about 30 percent of that increase can be accounted for by improvements in the reporting of deaths.
A study [PDF] released this year by the California Pregnancy-Associated Mortality Review Committee, which Main leads, says more research is needed on the relationship between C-sections and maternal deaths.
"It's actually a very hard one to tease apart, what the role of C-section is in maternal mortality," Main said, "but we do know it causes increased morbidity, or complications, so the thought is if you do enough of them, you're going to see more direct complications."
Main said the main risk comes when women have a second, third or fourth C-section. As the procedure's use increases, more women will have multiple C-sections, meaning the risks will be increasingly present in the future.
Although cesarean sections generally are a safe option for giving birth, The Joint Commission and the Agency for Healthcare Research and Quality both have endorsed reducing their use in certain types of pregnancies, the study says.
"Part of the problem is that no one has said – either the medical community or the public or the insurance companies – that we’re doing too many C-sections," Main said. "In the absence of that kind of pressure, it has floated up like a balloon."
In the study's other findings:
- While the use of C-sections is increasing, the number of hysterectomies is falling. Hysterectomies, surgeries to remove the uterus, still account for nearly 80 percent of all gynecologic surgeries, but the number of hysterectomies has decreased by 31 percent since 2002, mostly thanks to the availability of less invasive treatments.
- The study gave hospitals in the 19 states ratings of one, three or five stars based on maternal care and gynecologic surgery between 2007 and 2009. In California, 57 hospitals received five stars for maternal care, and 117 received five stars for gynecologic surgery. To see how a specific hospital fared, search for it here.
- About 7 percent of women in single-baby labor and 9 percent of women having gynecologic surgery experienced complications while in the hospital. The study estimates that 32 percent of complications during delivery (141,869) and 35 percent of complications during surgery (30,675) could have been prevented if all of the hospitals had performed at the level of the five-star winners.
"Women can optimize their chances for receiving the highest possible quality of care by researching and comparing the clinical outcomes of hospitals and doctors in their area," Dr. Divya Cantor, senior physician consultant at HealthGrades, said in a statement.