Cesarean delivery rates have been rising across the country for a decade. But state public health specialists are trying to understand why the rates are higher at some Massachusetts hospitals than others.
Raw numbers of Cesarean births, meaning rates that don't take into account risk factors for mothers and babies or complications during labor and delivery, show that five community hospitals, including one that serves high-risk women and newborns, had the highest proportion of Cesareans. The five lowest rates were also at community hospitals. Teaching hospitals with high-level neonatal intensive care units, where one might expect women with high-risk pregnancies to go, are closer to the state average of 34.4 percent.
Here are the five highest C section rates as a percent of all births in 2008, unadjusted for risk factors:
Holy Family Hospital, Methuen: 47.4
Melrose-Wakefield Hospital, Melrose: 45.7
South Shore Hospital, Weymouth: 43.9
MetroWest Medical Center-Framingham Union Hospital, Framingham: 41.8
Signature Healthcare Brockton Hospital, Brockton: 41.1
The five lowest:
Heywood Memorial Hospital, Gardner: 16.2
North Adams Regional Hospital, North Adams: 18.2
Tobey Hospital, Wareham: 19.1
Holyoke Medical Center, Holyoke: 21.6
HealthAlliance Hospital - Leominster Campus, Leominster: 22.2
State average: 34.4
Dr. Lauren Smith, medical director of the Massachusetts Department of Public Health, emphasized that while there is no magic number for the percentage of births that should be Cesarean deliveries, state analysts want to know why rates differ so markedly. A separate analysis based on births from 2004 through 2006 found that when hospitals were divided into three groups based on the complexity of obstetrical care they provided, the Cesarean rates still varied widely within those groups. Risk was taken into account after looking at birth certificates and other records.
"There are a complex array of factors that contribute in each individual case to whether or not a woman delivers vaginally or via Cesarean," Smith said in an interview. "And some of those are factors are at the hospital level, such as how do they organize the staffing of their labor and delivery units, what are the resources that might be available, ... is it a teaching facility, are there residents or attending [physicians], how many delivery rooms or operating rooms do they have."
Dr. Paul Allen, vice president of medical affairs at Holy Family Hospital in Methuen, said the decision is made between the patient and the physician. Holy Family had the highest Cesarean rate in the state, at 47.4 percent.
"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."
In 2008, the rate was zero.
At Melrose-Wakefield Hospital, which had the second highest Cesarean rate, Dr. Bernard Logan said the hospital doesn't have an answer for its 45.7 percent rate. "We do review the cases," he said. "We have excellent outcomes with healthy babies and healthy mothers."
About 2 to 3 percent of the rate may reflect the hospital's policy of referring to teaching hospitals women who have had Cesareans but want to deliver their next baby vaginally, said Logan, who is chair of obstetrics and gynecology at the hospital's parent company, Hallmark Health.
South Shore Hospital's third-highest rate of 43.9 percent is explained by the needs of its patients, said Dr. Veronica Ravnikar, chair of obstetrics and gynecology. "We have a Level III [neonatal intensive care unit] staffed by Children's Hospital pediatricians and neonatololgist and we have a Level III maternity center in which we take care of women who are high risk on the South Shore. Those two things distinguish us."
South Shore also has an affiliation with Brigham and Women's Hospital that brings patients who have had fertility treatments to the Weymouth hospital. Those women tend to be older and are more likely to have multiple births, both of which raise the chances a Cesarean, Ravnikar said.
The Cesarean rate was 35.2 percent at the Brigham, where its 8,115 total births leads the state.
While individual women may have health conditions or preferences that come into play when choosing between Cesarean or vaginal deliveries, DPH's Smith said, the hospital picture is still puzzling.
"We are observing a substantial increase over time," she said, from about 1 in 5 deliveries being Cesareans in 1997 to about 1 in 3 in 2008. "Then we observe the two-, three-, and four-fold variation at the hospital level. We just want to understand why."
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