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Hospital C-section rates show wide swing

State findings in low-risk cases raise questions

By Deborah Kotz
Globe Staff / May 17, 2011

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A state report released yesterday found a wide variation in the frequency of caesarean sections at Massachusetts hospitals, in an analysis restricted to first-time mothers with low-risk pregnancies who would be least likely to need the surgery.

The Department of Public Health report showed that the caesarean rates for these low-risk women ranged from 10 percent to 35 percent among the hospitals in 2009, the most recent year for which the data are available.

“This degree of variation suggests all are not practicing the procedure at the ideal rate,’’ Dr. Lauren Smith, the agency’s medical director, said in an interview.

State health officials, saying they were surprised and mystified by the wide variation, released the findings at a meeting yesterday with representatives from 49 hospitals that perform deliveries in the state. The officials hope to get the hospitals’ help in rooting out unnecessary caesareans.

About 1 in 3 pregnant women in the state delivered by caesarean section that year, compared with 1 in 5 in 1997. Yet there has been no corresponding decline in infant mortality rates, causing many to question the rationale behind the increase.

Standard caesareans cost about $3,500 more, on average, than a vaginal delivery, according to the March of Dimes, an advocacy and research group that helped organize the conference.

And they are often elective and performed before a baby is full-term at 39 weeks, which has been shown to increase the rate of respiratory problems, feeding disorders, and neonatal intensive care unit admissions.

In a report card issued last year, the March of Dimes gave Massachusetts a grade of C for its 10.8 percent preterm birth rate, defined as before 37 weeks, since it failed to meet the federal government’s goal of 7.6 percent for the nation. (No states, though, received A’s or B’s and many received F’s.)

The state has previously published overall caesarean rates for hospitals, showing roughly a twofold variation, but because some hospitals treat many more women with high-risk pregnancies, those data were hard to interpret.

The new analysis, looking only at mothers with low-risk pregnancies who delivered at full-term, was designed to put hospitals on a more level playing field.

Smith declined to release the rates for each hospital from the new analysis, saying they could mislead consumers, who might wrongly conclude that the hospitals with the lowest rates are the most desirable.

She said specialists have not identified what the ideal caesarean rate should be for women with uncomplicated pregnancies, nor do they know why rates vary so widely among hospitals.

She said a host of factors could contribute, from patient preference to hospital policies to doctors’ individual beliefs about risks to the baby if a labor continues for too long without progressing.

What is clear, Smith said, is the need to gather more data and determine whether hospitals with the lowest caesarean rates have the best health outcomes for both mother and baby. That will take better collaboration and data sharing among hospitals.

“The issue is, can our hospitals do things even more effectively together than individually?’’ said Smith. “We know that many are struggling with the same issues.’’

There was wide support for sharing more information among attendees at yesterday’s conference, held at the Massachusetts Medical Society in Waltham.

“I think it would be wonderful,’’ said Dr. Jeffrey Ecker, a high-risk obstetrician at Massachusetts General Hospital. “It would allow better quality and safer care, since the successes of one institution could be replicated across the state.’’

Dr. Glenn Markenson, an obstetrician-gynecologist at Baystate Medical Center in Springfield, said he was surprised by the lack of controversy over the idea of sharing sensitive information like complication rates from vaginal and surgical deliveries.

But, he added, the report is being viewed by many as a wake-up call for hospitals to start figuring out what works best to reduce the number of caesareans, the most common surgery in the United States, with about 1.3 million performed a year.

Efforts to reduce unnecessary caesareans may have resulted in some positive shifts. For the first time in years, caesarean rates did not rise in 2009 and appeared to be on a slight decline; that could be due to a trend toward allowing women to have vaginal births after caesareans. (The latest research indicates such births are safe for most women.)

“That’s possible,’’ said Smith, “but it’s purely speculation, and we have to see if this is a downward trend’’ or a statistical blip.

Also, some hospitals represented at the conference, including Massachusetts General and Baystate, have recently instituted strict policies to reduce elective births before 39 weeks by allowing them only when there is a clear medical need, such as high blood pressure in the mother or a lack of growth in the baby.

Research presented by the March of Dimes at the meeting found that such policies led to reductions in admissions to neonatal intensive care units at several hospitals across the country without any increase in stillbirths.

In January, some 25 hospitals across five states, including California, Texas, and New York, agreed to adopt this policy, a move that the March of Dimes hopes will be replicated by all the hospitals in Massachusetts.

“Just based on today’s conference, there’s a lot of interest in collaboration,’’ said Dr. Scott Berns, senior vice president of chapter programs for the March of Dimes. “They’re asking, what are the next steps?’’

Deborah Kotz can be reached at dkotz@globe.com.

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