Cesareans more likely for women at for-profit hospitals, study finds

For-profit hospitals across the state are performing cesarean sections at higher rates than nonprofit hospitals, a California Watch analysis has found.

A database compiled from state birthing records revealed that women were at least 17 percent more likely to have a cesarean section at a for-profit hospital than at a nonprofit or public hospital from 2005 to 2007. A surgical birth can bring in twice the revenue of a vaginal delivery.

In addition, some hospitals appear to be performing more C-sections for nonmedical reasons -- including an individual doctor's level of patience and the staffing schedules in maternity wards, according to interviews with health professionals.

The statewide database revealed significant differences among 253 hospitals in California. New mothers with low-risk pregnancies had a 10 percent chance of giving birth by C-section at the public Santa Clara Valley Medical Center, for example, whereas low-risk pregnancies at the for-profit Los Angeles Community Hospital ended in a surgical birth nearly half of the time.

The numbers provide ammunition to those who have long suspected that unnecessary C-sections are performed to help pad the bottom line.

"This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate," said Desirre Andrews, president of the International Cesarean Awareness Network, a nonprofit group that would like to see C-sections only in cases of medical need.

This was the first independent analysis of C-section rates at the 253 hospitals reporting birth statistics to state health authorities. The data focuses on low-risk pregnancies where cesareans are more likely to be unnecessary -- excluding deliveries by older mothers, women with certain medical conditions and women with previous C-sections.

But some hospital officials dispute the notion that their institutions could be pushing C-sections for money. "Decision-making about C-section versus vaginal birth is between a doctor and the patient, and our goal is to support that decision-making process with evidence-based practices," said Leslie Kelsay, a spokeswoman for Good Samaritan Hospital in San Jose, which had the highest cesarean rate for low-risk pregnancies in Santa Clara County at 22 percent.

Rick Black of Tenet Healthcare, which owns a number of hospitals in California and elsewhere, agreed. "You don't just come into a hospital and they say, 'We want to give you a C-section so we can drive up profits', he said.

Gene Declercq, professor of community health sciences at the Boston University School of Public Health, agrees

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that hospitals would not explicitly push C-sections for profit. But subtle incentives to increase efficiency could have the same effect.

"It's a lot easier if you can do all your births between seven and 10 in the morning and know exactly how many operating rooms and beds you need," he said. Vaginal births are unpredictable, creating inefficiencies that can hurt the bottom line.

In 2008, more than 180,000 C-sections were performed in California.

Pressure for procedure

Even at some nonprofit hospitals, some women say they feel pressured to have a C-section. Rebecca Zavala, a teacher and makeup artist in Ventura, is one.

Zavala, 29, 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. But complications arose during the procedure, conducted at the nonprofit Santa Monica-UCLA Medical Center.

After several hours, her doctor informed Zavala that her baby was showing signs of distress and recommended a C-section. Zavala agreed.

But Zavala said she felt manipulated. Her doctor hadn't told her that induction increased the likelihood that she'd have a C-section, and that C-sections came with health risks, she said.

"She told me nothing," Zavala said of her doctor, noting that the doctor left for her vacation shortly after the delivery.

Zavala's doctor would not comment. The hospital could not discuss the specifics of the case because of patient privacy but responded with the following statement:

"Our policy requires physicians to obtain informed consent from patients undergoing C-sections. The process, which we followed completely, involves discussing the risks, benefits and alternatives to the procedure, and documenting that the discussion occurred and the patient opted to proceed."

Zavala did sign the consent but said it was impossible for her to interpret and assess the issues laid out in small print. Santa Monica-UCLA Medical Center has one of the highest rates of C-section deliveries in the state, ranking 15th out of 253 hospitals, for women whose pregnancies were deemed to be low-risk.

For some, a C-section can have devastating consequences.

Heather Kirwan said her doctor at the for-profit Rancho Springs Medical Center in Murrieta urged her to have a C-section, warning that the baby was too big for her birth canal. She reluctantly agreed.

"She ended up being a 5-pound, 12-ounce baby," said Kirwan, 26, a manager for The Home Depot who lives in Murrieta, and who now believes she could have delivered vaginally.

When Kirwan got pregnant again, doctors discovered the embryo was developing outside the uterus -- a life-threatening condition called an ectopic pregnancy which is more likely to occur after a C-section. The embryo was removed along with one of Kirwan's ovaries and fallopian tubes. She has been unable to conceive since.

Kirwan's doctor and Rancho Springs Medical Center didn't respond to requests for comment. The hospital's C-section rate is among the state's lowest, ranking 207th out of 253 medical centers.

Searching for a link

Medical experts have been unable to pinpoint exactly why some hospitals perform far more C-sections, or "operative deliveries," than other medical facilities.

Yet one important factor has always loomed over the debate about the rise in C-sections: the bottom line. In California, hospitals can increase their revenues by 82 percent on average by performing a C-section instead of a vaginal birth, 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, and profits for a comparable vaginal birth were $1,230.

California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus -- positioned head down -- at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, and for-profit hospitals had a rate of 19 percent.

That may seem like a small percentage gap to the casual observer, but medical experts consider it significant. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital.

"That's a decent-sized difference," said Declercq, of Boston University School of Public Health.

Less than one in five maternity hospitals in the state is a for-profit institution, but among the 15 hospitals with the highest rates of C-sections, 10 are for-profit facilities. Among the 15 hospitals with the lowest rates, none are for-profit medical centers.

Riverside County Regional Medical Center in Moreno Valley has one of the lowest C-section rates for low-risk births 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.

"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."