California sees slight dip in C-section rates, but challenges remain

California's hospitals have scored modest gains in their efforts to minimize the number of Cesarean sections performed on women at low risk of complications, according to data released Monday. But the data also show that as a group, the state's medical facilities still have not hit a national target and many remain far from reaching the goal.

In addition, there continues to be wide variation in how facilities perform on this measure, says Dr. Bruce Spurlock, executive director of the California Hospital Assessment and Reporting Task Force, a multi-stakeholder group that published 2014 data on hospital performance.

"Californians deserve better care and more active improvement than we've seen," Spurlock says.

The task force analyzed state data from 244 hospitals regarding C-sections performed on first-time moms with low-risk pregnancies, defined as those that have reached the 37th week or later and consisting of one fetus in the head-down position. (The technical term for this type of pregnancy is Nulliparous Term Singleton Vertex.)

Statewide, the average rate of these types of C-sections dropped from 27.4 percent in 2013 to 26.5 percent in 2014, according to the new data. The federal government has set a goal of reducing C-sections in low-risk pregnancies to 23.9 percent by 2020.

The average rates mask the wide variation among hospitals: The top performing 10 percent of hospitals had C-section rates of 19 percent or lower. Meanwhile, the worst performing 10 percent had rates of 33 percent or higher. The number of births at a hospital doesn't seem to be a factor, since there is a mix of facilities with high and low volumes throughout the rankings.

Complications can arise in low-risk pregnancies, and in those cases, C-sections can save the lives of mothers and infants. But experts say the procedure, which is major surgery, is frequently performed when it is not medically indicated. 

C-sections carry with them the risk of bleeding, infection, blood clots and injury to other organs. First-time mothers who undergo the procedure are very likely to have it again with future births, and that brings risks of additional complications, experts say.

Like the rest of the state, there is wide variation in the performance of Southern California hospitals.

Loma Linda University Medical Center in Murrieta and La Palma Intercommunity Hospital in northern Orange County both performed C-sections on less than 20 percent of first-time moms with low-risk pregnancies in 2014, according to the data. Loma Linda brought its rate down from 23.7 percent in 2013 to 18.1 percent in 2014; La Palma dropped its rate from 21.1 percent in 2013 to 17.5 percent in 2014.

Kaiser Permanente of Woodland Hills also achieved a significant decrease, from 25.7 percent in 2013 to 19.3 percent in 2014.

Dr. Jeffrey Martin, chief of obstetrics and gynecology at Kaiser Woodland Hills, says the hospital has taken a number of steps to reduce its C-section rate. One key change, he says, is that doctors now allow first-time moms who are fully dilated to push for an hour longer than they previously did before the physician will recommend a C-section.

"The data shows that if we allow women to continue to push in that second phase of labor, assuming the baby is doing well, there's a higher chance of them having a vaginal delivery than we used to think," he says.

At the high end of the rankings, Memorial Hospital of Gardena and Sun Valley-based Pacifica Hospital of the Valley both performed C-sections on more than half of moms with low-risk pregnancies in 2014 - 55.4 percent at Memorial and 55.7 percent at Pacifica.

In a statement, Memorial CEO Kathy Wojno says she's disappointed by the hospital's C-section rate.

"The health and wellbeing (sic) of the communities we serve is paramount, and it worries me that patients will see our scores and mistakenly determine that we are not providing high quality maternity care," Wojno says. "That's just not true."

The facility has hired a perinatologist who's available around the clock to consult with obstetricians when patients develop pregnancy complications, she adds.

The persistence of high C-section rates is in part a reflection of hospitals' labor and delivery units developing cultures that don't prioritize "supporting normal birth," says Dr. Elliott Main, director of the California Maternal Quality Care Collaborative, which helped analyze the data released by the Task Force.

Beginning next month, the Collaborative will launch a program that aims to reduce unnecessary C-sections. Main says mentors will work with eight hospitals at a time to identify and share best practices.

"In this way, hospitals can share their successes, their barriers, and the strategies to overcome them," he says. This technique, he adds, has also been used to cut the state's maternal mortality rate in half over the past five years.

Memorial Hospital of Gardena's Wojno says that her facility will be one of those working with the Collaborative.

The Leapfrog Group, which focuses on hospital safety and quality, released statewide and hospital-level C-section data last fall. But more than 45 percent of California hospitals declined to respond to its survey.

California Hospital Assessment and Reporting Task Force data on NTSV* C-section births at Southern California hospitals

*NTSV (Nulliparous Term Singleton Vertex) births involve a first-time mother at full term carrying one baby in the head-down position.