SSM Health St. Mary’s Hospital in Richmond Heights has the second lowest C-section rate among large hospitals across the country for first-time low-risk mothers, according to a Consumer Reports analysis of data. At just 12.3 percent, the rate is far below the 24 percent statewide average.
The analysis of data from more than 1,300 hospitals across the country confirms research that shows how C-section rates — even among low-risk births — can vary dramatically from hospital to hospital.
The rate at St. Louis area’s busiest labor and delivery department, at Mercy Hospital St. Louis, is 28.7 percent.
A low-risk birth is defined as a first-time mother giving birth to a single, full-term and head-down baby. Dr. Neel Shah, an obstetrician and researcher at Harvard Medical School, told Consumer Reports that while obesity, age and other chronic conditions can make it more likely for a woman to have a C-section, the biggest risk factor is “the hospital a mother walks into to deliver her baby, and how busy it is.”
Cesarean birth can be live-saving for the fetus and the mother. However, the rapid rise in C-sections over the past 20 years — to one in every three births — has raised concern that the surgery is overused. The increase has not improved outcomes. Instead, maternal mortality has been on the rise in the U.S.
Wide variations in the C-section rate among low-risk births also indicate doctor and hospital practice patterns, rather than health factors, play a role. The rate is as low as 17 percent in New Mexico and as high as 32 percent in Louisiana, according to Consumer Reports. The national target is 23.9 percent.
The rate varies more among hospitals, from 7 percent at Crouse Hospital in Syracuse, N.Y., to 51 percent at South Miami Hospital in Florida.
The fear of malpractice lawsuits also drives the numbers, said Dr. Gilad Gross, medical director of labor and delivery at St. Mary’s. Performing a C-section means doctors tried everything they could at any sign of trouble.
“We really try to stick to the evidence and not really let the medical legal threat get in the way of medical decision-making,” Gross said. “We try not to practice under that atmosphere.”
Efforts behind St. Mary’s low rate, he said, include letting women labor longer before intervening, avoiding unnecessary inductions, letting labor start naturally, hiring three nurse midwives and promoting better understanding of fetal heart-rate readings. Research shows all these steps can reduce the C-section rate without placing mothers and babies at risk.
“We try not to intervene unless we have to,” said Dr. Greg Ward, obstetrics chief at St. Mary’s. “We do not let the time of day or our schedules affect patient care, and we do not put time limits on labor if everything is looking good.”
Dangers for women, babies
The Consumer Reports analysis used data gathered by the Leapfrog Group, a national nonprofit founded by large employers and other health insurance purchasers. Through a hospital survey, the group collects and reports hospital performance data.
This is the first year all SSM Health and Mercy hospitals in the St. Louis area have participated in the survey. Area BJC HealthCare facilities opted out. BJC officials said in an email that they chose not to participate because of the survey’s reliance on self-reported numbers, and billing and claims data, which they say are not accurate ways to compare quality of care.
Average C-section rates at area BJC hospitals over the last six months were “slightly above the national average,” of 25.8 percent, officials said. BJC hospitals Missouri Baptist Medical Center, with 4,000 births a year, and Barnes-Jewish Hospital, with nearly 3,300 births, are among the area’s busiest labor and delivery departments.
While life-threatening complications are rare, women with low-risk pregnancies undergoing their first C-Section are three times more likely to die or suffer serious complications such as massive bleeding, anesthetic complications, heart attack, blood clots and infection, according to a large study in Canada published in 2007.
The biggest concern is with multiple C-sections. Nearly all women who have a C-section with their first baby repeat the surgery again for future births. This greatly increases the risk of the placenta’s implanting over the cervix or the surgical scar, a thin spot in the uterus, which can be very dangerous for moms and babies.
“We have skilled nurses and midwives and obstetricians that are committed to giving patients the best possible shot at the first delivery,” Gross said, “so we can set the women up for hopefully a lifetime of successful vaginal deliveries.”
Sara Grabowski’s doctor suggested she have a C-section with her first baby because of a prior uterine surgery. When she got pregnant a second time, her placenta implanted over both her C-section scar and her cervix.
Grabowski, 36, of Fairview Heights, delivered her daughter Aug. 16 six weeks early under general anesthesia. She lost dangerous amounts of blood and had to have a hysterectomy. Her baby spent 16 days in intensive care.
Grabowski said she had been unaware of the risks that lie ahead after a first C-section and wanted other women to be educated.
“If I had known, maybe I would’ve pushed hard to have a vaginal delivery” if it wasn’t too risky, she said. “I just didn’t know that this condition existed, or that it was a possibility.”
Cost is another factor. The average cost of a normal newborn delivery is $10,788, while a C-section is $15,638 with no complications and upwards of $19,790 with complications, according to Missouri hospital data.
The American College of Obstetricians and Gynecologists issued guidelines in 2014 to help providers decide when a C-section is needed. The guidelines challenged two of the biggest reasons for first-time C-sections: stalled labor and abnormal electronic fetal heart-rate monitoring.
The guidelines included recent evidence that shows first-time mothers dilate more slowly than previously thought and can safely take longer to push.
The guidelines also called for a standardized approach in interpreting the readings of fetal heart-rate monitors, used in about 85 percent of births. While some readings are clearly normal and others clearly abnormal, the most common are “intermediate,” which are open to interpretation.
“How do you take something that is so subjective and make sure that everyone applies it and uses it in the same fashion?” Gross said. Staff at St. Mary’s studied the practice closely and educated doctors and nurses about when readings indicate an emergency.
“The fetus is very well-equipped to care for itself and correct itself during labor. As long as you understand and trust the process, you feel comfortable to continue,” he said.
Last week at St. Mary’s, patient JaiDa’h Jackson, 17, was in labor for 28 hours after her water broke. The baby showed signs of mild distress several times, but simple interventions helped the young mother avoid surgery, nurse midwife Becky Hassler said.
Interventions included changing the patient’s position, giving her oxygen through a face mask and using medication to briefly stop contractions and give the baby a break.
Each time, the baby recovered well, Hassler said. “Patience and careful review of the whole picture are crucial during these situations.”
Dr. Craig Boyd, the chair of obstetrics at Mercy St. Louis, said Mercy was also working to follow the new guidelines. At more than 9,000 births a year, change may take longer to take hold.
The hospital is giving physicians feedback on their practice patterns, Boyd said.
Nurses are also seen as key players, he said. They can set expectations and reassure women when they are in labor. The hospital also educates parents-to-be in its prenatal classes about the normal progression of labor and risks of a C-section.
Nearly three years ago, Mercy opened a birth center staffed with midwives, who are trained to support women seeking a natural birth.
The rate of C-section for low-risk women is 6 percent at birth centers, studies show. The St. Louis area has one free-standing birth center, the Birth and Wellness Center in O’Fallon, Mo.
While St. Mary’s is leading the way among large hospitals across the country, other SSM Health hospitals such as St. Clare in Fenton and St. Joseph in St. Charles show some of the area’s highest rates of C-sections for low-risk mothers — 29.1 and 29.7 percent.
SSM Health’s chief medical officer for the St. Louis Region, Dr. Alexander Garza, suspects that’s because of the lower number of births at the hospital, where a few cases can cause big percentage changes. St. Mary’s is also a high-risk birth facility, he said, which makes staff more confident and comfortable when it comes to caring for low-risk patients.
Grabowski encouraged women to ask their providers about their C-section rates and when they feel the procedure is necessary.
“You should feel comfortable talking to your doctor about what your options are,” she said, “and if you don’t feel comfortable, find someone who you think will listen to your concerns.”
Area C-section rates for low-risk births
Results are from a Consumer Reports analysis of data. BJC did not participate in this survey. Hospital officials said average C-section rates at local BJC hospitals over the last six months were “slightly above the national average,” of 25.8 percent.
|Hospital||C-sections for low-risk births||Annual number of births|
|SSM Health St. Mary's Hospital||12.3 percent||3,454|
|SSM Health St. Joseph Hospital, Lake St. Louis||12.4 percent||917|
|SSM Health DePaul Hospital||16.5 percent||966|
|Mercy Hospital Washington||27.4 percent||861|
|OSF Saint Anthony's Health Center||28.6 percent||311|
|Mercy Hospital St. Louis||28.7 percent||9,019|
|SSM Health St. Clare Hospital||29.1 percent||1,104|
|SSM Health St. Joseph Hospital, St. Charles||29.7 percent||731|
|St. Anthony's Medical Center||31.6 percent||1,075|
|Mercy Hospital Crystal City||37.7 percent||406|