Steadily climbing C-section birth rates in Ohio and US alarm health experts

CLEVELAND (AP) — New data on Cesarean births in Ohio points to a troubling trend of unnecessary surgeries.

The state’s new hospital- performance Web site, Ohio Hospital Compare, shows that more than one-quarter of first-time mothers considered unlikely to need Cesarean surgery underwent C-sections anyway in 2008.

The figures are consistent with a national Cesarean-birth rate that has climbed steadily since 1996.

Cesarean surgery is called for when there are problems such as the baby is turned in the wrong direction. But across the nation, almost one in three births is now by C-section, and criticism has grown from health experts and birthing organizations.

Ohio health officials, under a mandate to collect and report hospital-quality measures, are trying to put a finger on the problem by looking at C-section rates among women least likely to need one. They excluded mothers who have complicating issues.

Among 117 hospitals they found wide variations in C-section rates for these low-risk women. Experts said at the very least, the data raises questions about whether hospitals with high C-section numbers are doing too many surgeries, which heighten health risks to mother and child and lengthen hospitalizations.

Seven hospitals in the Cleveland-Akron area had rates exceeding 30 percent, which are among the highest in Ohio.

“We want to look at hospitals [with high rates] to see if all these women need C-sections,” said Dr. Edward Donovan of the Ohio Perinatal Quality Collaborative. “There’s huge variation that no one quite understands. We have a lot of work to do to figure this out.”

After viewing the state data, a Medical Mutual of Ohio official said the insurer also will look into whether some hospitals are performing unnecessary C-sections. “We’ll show it to people and see if they have explanations and go from there,” said Dr. Robert Rzewnicki, chief medical officer of Medical Mutual.

The state report subjects hospitals to public scrutiny like never before. But it remains unclear why so many women who were low-risk had C-sections.

Many are thought to be tied to scheduled deliveries, which may be planned as C-section births or turn out that way if induced labor does not progress well.

“I don’t want to say it’s out of convenience, but for most people, these were Cesarean sections scheduled in advance,” said Kaliyah Shaheen of the Ohio Department of Health, which collected and published the data. “For the most part, these probably weren’t necessary.”

Dr. Michael Gyves, an obstetrician and associate professor at Case Western Reserve University, disagreed.

Elective Cesareans represent a small percentage, he said. In most cases, the decision is made because of problems that arise during labor. Doctors may call for surgery if labor is not progressing or if the baby’s heart rate falls. But Gyves also said that judging when a baby needs to be delivered surgically is an imperfect discipline, and fear of being sued over a potentially problematic vaginal birth often plays into the decision.

Obstetrician-gynecologists shoulder some of the steepest malpractice insurance rates around.

“Overall [the C-section rate] is probably higher than it should be, and it reflects the defensive practice of obstetrics,” Gyves said.

Pam Kolanz, who runs the Greater Cleveland chapter of the International Cesarean Awareness Network, said the variation among hospitals suggests institutional attitudes about vaginal births differ hospital to hospital.

“Women are being approached differently,” she said. “Consumers need to be vigilant in their choice of health providers. The place of birth is very likely to determine whether they’re going to have a Cesarean or not, and the numbers show that.”

Dr. Tommaso Falcone, chairman of obstetrics and gynecology at the Cleveland Clinic, acknowledged the problem and said his task is to change the culture at community hospitals where rates are high.

At Clinic-owned Huron, Hillcrest, Marymount, Fairview and Medina hospitals, more than 30 percent of births to low-risk mothers were by C-section, the state report showed.

“Obviously these rates are high, and we’re trying to address this,” Falcone said. “There’s a culture in certain groups, in certain areas where people say, ‘What’s wrong with a high C-section rate, as long as the baby is fine.’”

Erin Denney, a 38-year-old mother of six, would not be counted in the new state measure because her first three children were born by C-section. But Denney said she ran up against cultural resistance when she sought to deliver her later children vaginally.

Her story highlights another reason C-section rates are high. A growing number of hospitals nationwide have banned vaginal births after C-section, due to risk of rupture of the uterus. That risk for women with the most common type of incision is 0.2 percent to 1.5 percent, according to the Mayo Clinic’s online “Vaginal Birth After Cesarean (VBAC) Guide.”

About one-quarter of obstetrician-gynecologists said in 2009 that they stopped performing vaginal deliveries after C-section because of liability concerns, according to a professional society survey.

The practice is driving the national C-section rate, according to the International Cesarean Awareness Network.

Denney, who lives in Parma Heights, said she had to search hard to find providers that would allow her to give birth naturally.

“They will push you to have a C-section,” she said. “It’s actually safer to VBAC than to have a C-section.”

Efforts under way in Ohio should improve C-section rates, said Shaheen of the state health department.

The Ohio Perinatal Quality Collaborative has worked with hospitals since 2007 to reduce the numbers of planned, pre-term deliveries, which are associated with high C-section rates and increased risk of other health problems.