Cesarean stats and reality?

[AmyKT]

I have read that c-section stats are around 30% in the US right now, so why is it that of the last 10 births I know of, around 7-8 have been by cesarean? Is it a class thing? My friends and acquaintances are fairly well-off and have private health insurance. Many of the sections are repeats, but still -- I don't understand why I know so many if fewer than a third of births are cesarean? Maybe it's regional. I'm in the southern US.

Who is having the vaginal births in the US aside from crunchy women like we find on MDC? There aren't that many of us in the US. Is it low-income women? Does medicaid cover c-secs? Illegal immigrants and other uninsureds? I'm really just curious that I don't know more of the 70%.


ETA: sorry, in my first paragraph I meant to say "well-off", not "well-educated"

[MegBoz]

Originally Posted by AmyKT

I have read that c-section stats are around 30% in the US right now, so why is it that of the last 10 births I know of, around 7-8 have been by cesarean? Is it a class thing? My friends and acquaintances are fairly well-educated and have private health insurance.

Yup! You guessed correctly. It is indeed a class thing.

Women with private insurance in private hospitals are more likely to have a CS. Can't recall specifically where I read that, but I would guess in the book "Born in the USA" by Dr. Marsden Wagner.

Yes, the 2008 CS rate was 32% and some change. I believe New Jersey was the state with the highest rate. I know NYC is pretty high too, but other than that I'm not sure of regional variations.

[kltroy]

It also varies wildly from one city to the next - and even from one hospital to the next. Our Dept of Public Health keeps statistics in births and c-sections for each hospital. The c/s rates range from 52% at the high end (yikes!!) to around 15% at the low end. Some of this has to do with whether VBAC is allowed at a hospital (figure repeat c-sections account for about 30-40% of all c-sections), who attends the births (midwives and family practice doctors have a lower c-section rate than OB/GYNs generally), and the socio-economic factors and insurance mentioned above.

[phathui5]

Medical assistance absolutely does cover c-sections.

Repeat C-sections could definitely be a factor. Using an OB is a possible risk factor too. If you're using a midwife, I think you're not likely to end up with an unnecessary C-section, whereas with an OB, they generally don't try to avoid them.

[Drummer's Wife]

yeah, medicaid definitely covers c-sections - elective even if the doc allows it (many do, of course).

I also agree that repeats are a big part of that percentage. Many of women, myself included, just don't have an option beside UC at having a shot at a vaginal birth. Which is why I think reducing the primary c-section is so important (as is changing the birthing climate where providers and hospitals don't vbac/vbamc).

And yes, having an OB ups one's risk, as does laboring in a hospital. I had two midwives for my first baby (one was my own mom), and yet I was sectioned eventually. I also chose to see midwives for prenatal care the next 3 pregnancies, and had a failed vba2c attempt - with a midwife. I do wish I had opted for a homebirth for my first, as obviously the chance of interventions would have been lower.

[sharr610]

sorry, posted some bad stats...

[harli]

I have experienced the same thing. Out of the people I know who gave birth at our local hospital the c-section numbers don't match up to this particular hospitals stats, which are exactly at US average. I never thought much of it until I was discussing it with a doula who works with that hospital said she was told by a L&D nurse that their C-section rates are much higher (closer to %60 which would match my own observations) and that they fudge the numbers when it comes time to report them. I know this is a stretch and definitely not reliable but it matches up bits and pieces of stories I've heard from others (such as a nurse friend who got out of L&D there because of the 'incredibly high amount of c-sections being done'). Just gives me one more reason for that hospital to give me the heebie jeebies.

I will admit though it does make me curious about how the reporting process works. Does the hospital give that info to a reporting agency? In which case it can't be trusted. Or does someone from the reporting agency go through all their L&D records for a year? Which would be more reliable but less realistic.

[AlexisT]

The issue isn't whether Medicaid will pay for a CS (of course it will); it's whether providers behave differently with poor patients, and whether middle class women have different cultural expectations. Middle class and up women are also likely to be older, which ups your likelihood of a section.

Local culture is an enormous influence--doctors practice like their peers (this is true of fields other than obstetrics, too). If a hospital culture is pro-vaginal birth, providers practice according to that standard. If the culture is cut-happy, they'll do that.

Sometimes, especially when talking about small groups, it also doesn't mean anything about the hospital. Half my antenatal group of 12 women, all first timers, had sections. Local hospitals had CS rates around 25%. We were all on the NHS, so provider/insurance differences were minimized. Age was probably a factor (average age over 30, 2 near 40), but otherwise? Probably a fluke. No one could've predicted the non-vertable breeches, the preeclampsia, etc.

[AlexisT]

The hospital has to report them to the state health department. I expect each state has its own system for reporting statistics.

My problem with the accusations of fudging the stats is this: they have to be reporting correctly to insurers. CS results in more revenue for the hospital. So, insurance companies wouldn't notice if they were getting claims for all these sections while the official statistics were half as much? If fraud is out there, it can't be widespread.

[harli]

Originally Posted by AlexisT

My problem with the accusations of fudging the stats is this: they have to be reporting correctly to insurers. CS results in more revenue for the hospital. So, insurance companies wouldn't notice if they were getting claims for all these sections while the official statistics were half as much? If fraud is out there, it can't be widespread.

I thought of this too. But that would mean it's up to the ins. company to
1) care enough about the states stats and their own to check into it.
2) actually have the time and funding available to check into it
3) say/do something about it if their is a discrepancy.

I'm not 100% convinced that they would care. Honestly I really think that it would be up to an independent researcher to look into it. I'm not aware of any studies that have been done.

I'm also not convinced that their is # fudging going on here either just saying that the way the current system most likely works is that it could probably be pretty easily done, and it would be in the hospitals best interest to do so.

[AlexisT]

I think it might be possible on a small scale without the insurers noticing, but it's impossible for any large number of hospitals to do it. Insurers would notice if their claims don't match the big national/state statistics that get published. They also do audit their claims--insurers don't really like paying more than they should.

I think there are also civil penalties for misreporting statistics to the state.

More importantly--the hospitals with really high CS rates don't care. They defend them and how they practice. The problem with the stats stories is that they assume that hospitals are ashamed of high CS rates, and IME, they aren't.

This is what the VP of the Massachusetts hospital with the highest CS rate in the state (47%) says:

"It's not a number that we place a lot of emphasis on," he said. "More important is the safety and quality of the outcome and if you look at the infant mortality rate at the hospital, we're really pleased with it. That's the number we are most concerned with."

[lach]

My experience is the opposite, which is interesting to me but does give credence to the coincidence argument. The hospital where I gave birth has a very high C rate, and I ended up with a C. But only one other mother in my playgroup (out of about 11 moms total) had Cs, and she went on to have a VBAC for her second child. It's definitely and upper middle class, older cohort and it's hospital with very high C section rates, so I would have thought that most of the women I know would have them.

So I do think that a lot of it is just coincidence. I have to admit (and here is where I know that I sound judgmental and not very nice) that I have a certain image of the type of woman most likely to have a C, and I tend to picture a wealthier, high-maintenance type of woman without much patience or faith in her body. But I have to admit to knowing a fair number of women who more or less fit that profile and they've almost all had vaginal births.

I will say that the hospital where I go has a very good NICU, so I think that it attracts people who have high risk pregnancies, and those women are probably more likely to have Cs. So that probably makes the rate higher than at a smaller hospital around here without such a good reputation for its NICU.

[mamabadger]

Originally Posted by AlexisT

This is what the VP of the Massachusetts hospital with the highest CS rate in the state (47%) says:
"It's not a number that we place a lot of emphasis on," he said. "More important is the safety and quality of the outcome and if you look at the infant mortality rate at the hospital, we're really pleased with it. That's the number we are most concerned with."

I sometimes hear comments like this, and it makes me wonder. Is this hospital's infant mortality rate really any lower than that of neighboring hospitals? If not, what use are all these surgeries? (Not to mention women being sent home recovering from major surgery not being counted as part of "safety and quality of outcome.")

[goldingoddess]

Originally Posted by MegBoz

Yup! You guessed correctly. It is indeed a class thing.

Women with private insurance in private hospitals are more likely to have a CS. Can't recall specifically where I read that, but I would guess in the book "Born in the USA" by Dr. Marsden Wagner.

Yes, the 2008 CS rate was 32% and some change. I believe New Jersey was the state with the highest rate. I know NYC is pretty high too, but other than that I'm not sure of regional variations.

This is completely incorrect the C-section rate has nothing to do with socio-economic status. I believe there is a study referenced in Pushed or maybe I heard it in The Business of Being Born. But I do remember internalizing the information because I was shocked. I'll try to look up the source in a minute.

My guess is that it is a regional thing If all the women are going to the same hospital then they may be getting the same care.

I could easily say, " 8 out of 10 women I know had homebirths, where are all the c-sections and hospital birthers.?"

[SublimeBirthGirl]

I teach natural birth classes and my students average 10-12%. I think those women who take a natural birth class help balance out the others. I personally know more women who've birth vaginally because of the circles I run in; but if I look at the more mainstream sources it seems a lot higher.

[shnitzel]

I think there are other factors at play. The hospital near me with a 40% csection rate is in an extremly upper class neighbourhood but most of the women have children later in life and I personally feel that can make things more complicated andat the very least makes the health care practitioners nervous

[bobandjess99]

i know that here, we have 2 local hospitals, and 1 has a very high c/s rate, like 70%, because they are the biggest nicu in the area, and ALL complicated births go through them....its still a ridiculous number, but thats how they justify it.