The most common surgery performed in U.S. hospitals isn’t on the heart or back or hips or knees. It’s a C-section. Roughly one of every three babies born in this country, or about 1.3 million children each year, are now delivered by cesarean section.  

While a number of factors can increase the chance of having a C-section—being older or heavier or having diabetes, for example—the biggest risk “may simply be which hospital a mother walks into to deliver her baby,” says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in this country and around the world.

A new Consumer Reports investigation of more than 1,200 hospitals across the country supports that. It found that C-section rates for low-risk deliveries among U.S. hospitals vary dramatically, even in the same communities and among similar institutions, and that in most hospitals the rates are above national targets.


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In many cases, cesarean sections are absolutely necessary. But often they are not: Researchers estimate that almost half of the C-sections performed in the U.S. are done in situations when babies could be safely delivered vaginally instead. And performing a surgical birth when it isn’t necessary poses avoidable risks to the mother and her child and needlessly raises costs, research shows.

Alarmed by that trend, the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM)—the nation’s two leading medical organizations that focus on childbirth—issued recommendations in 2014 aimed at safely reining in unnecessary cesareans.

“No one is saying that C-sections are never necessary, and no woman should feel guilty or somehow bad if they end up needing one,” says Elliott Main, M.D., the medical director of the California Maternal Quality Care Collaborative, a nonprofit organization that works to improve outcomes for mothers and babies in that state. “But mothers shouldn’t be coerced, directly or indirectly, into having a cesarean either, and making C-section rates public can give women the information they need when choosing where to deliver their babies,” he says.

Too Many C-Sections

Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk of needing a cesarean: pregnant women expecting just one child (not twins, triplets, or other multiples) whose babies are delivering at full-term in the proper position, which means coming out head first.

The target C-section rate for those births, set by the Department of Health and Human Services, is 23.9 percent or less. That’s 10 percent less than the rate for such births in 2007, which the government uses as a baseline from which to improve.

But many experts say that the ideal C-section rate for those births is even lower. “Getting under 24 percent for low-risk births is something all hospitals should be able to do, but for those deliveries, hospitals should be aiming even lower,” Main says.

Yet nearly six in 10 of the hospitals we looked at had C-section rates above the national target for low-risk births. That means that 40 percent of hospitals already achieved this goal. “This sends a message that almost all hospitals should be able to achieve this rate,” Main says.

The risk of having a C-section also varied depending on where in the country women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest.

Three states plus the District of Columbia had C-section rates of 30 percent or higher: Mississippi (31 percent), Kentucky (32 percent), Florida (32 percent), and D.C. (35 percent). And four states had rates below 18.5 percent: South Dakota (14 percent), Wyoming (17 percent), New Mexico (18 percent), and North Dakota (18 percent).

What Hospitals Say

The variation in first-time, low-risk C-sections among individual hospitals is even more dramatic. For large hospitals, they ranged from 11 percent at Crouse Hospital in Syracuse, N.Y. to 53 percent at South Miami Hospital in Miami. Hialeah Hospital, outside of Miami, had the highest C-section rate of all hospitals, with more than two of every three low-risk babies delivered there by cesarean.

We found wide variation even among hospitals in the same community. For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were.

That same pattern is found in states and cities throughout the country. Jersey City Medical Center outside of Newark, N.J. had a low-risk C-section rate of 35 percent, compared with 19 percent at Trinitas Regional Medical Center in nearby Elizabeth. In Southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at Riverside Community Hospital.



Experts say that even total C-section rates—which include cesareans for all births, not just the low-risk ones we focused on—should rarely be high. “Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non-medically indicated cesareans being done,” says Aaron B. Caughey, M.D., chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine in Portland and a lead author of the new ACOG/SMFM recommendations. “That’s not good medicine,” he says.

When asked to explain their high C-section rates, hospitals offered several responses.

Mark Rabson, corporate director of public affairs at Jersey City Medical Center, described how his hospital, which serves “a diverse metropolitan area with many socio-economic issues,” was working to lower C-section rates by, for example, reviewing the care of all providers whose cesarean rates are above 30 percent and offering them assistance in how they manage patients during labor. In addition, he says the hospital is now using midwives, healthcare professionals trained to avoid intervening in childbirth unless medically necessary, and people fluent in multiple languages to educate patients about cesareans.

Patricia Villa, a spokeswoman for Hialeah Hospital, told us “while there are many factors that impact a woman’s decision to have a cesarean section, we are focused on driving improvement in this area.” She also noted that the hospital had been recognized by the March of Dimes for it’s efforts to prevent elective early deliveries before 39 weeks.

Dori A. Alvarez, a spokeswoman for South Miami Hospital, simply said, “Our physicians work with each patient and family individually to determine the delivery plan that will have the best possible outcome for the mother and the baby.”

The University of Chicago Medical Center declined to comment, and Riverside Community Hospital did not respond to a request for a comment.

Large U.S. Hospitals With High C-Section Rates

There were 221 hospitals in the U.S. with C-section rates above 33.3 percent for low-risk deliveries. Hospitals with C-section rates above that received our lowest score. Twenty-four of them were hospitals that had a high volume of deliveries.

Hospital Name

C-section Rates
(First-Time Mothers, Low-Risk Deliveries)1

South Miami Hospital, Miami, Fla.
53
Hackensack University Medical Center, Hackensack, N.J.42
Covenant Medical Center, Lubbock, Texas42
Woman's Hospital of Texas, Houston, Texas
41
Palmetto General Hospital, Hialeah, Fla.38
Winthrop-University Hospital, Mineola, N.Y.37

Las Palmas Medical Center, El Paso, Texas2

37

Methodist Healthcare Memphis Hospitals, Memphis3

37
Baptist Hospital of Miami, Miami, Fla.
36
Medical City Dallas Hospital, Dallas, Texas
36
University of Texas Medical Branch, Galveston, Texas36

Clear Lake Regional Medical Center, Webster, Texas4

35
Doctor's Hospital at Renaissance, Edinburg, Texas35
Riverside Community Hospital, Riverside, Calif.35
Inova Alexandria Hospital, Alexandria, Va.35

Methodist Hospital, San Antonio, Texas5

35
Henrico Doctors' Hospital, Richmond, Va.34
St. David's North Austin Medical Center, Austin, Texas34
Heritage Valley Health System, Beaver, Penn.34
Sharp Mary Birch Hospital for Women and Newborns, San Diego, Calif.
34
Antelope Valley Hospital, Lancaster, Calif.34

Jackson Health System, Miami6

34
Saint Mary's Regional Medical Center, Reno, Nev.34

Virginia Hospital Center - Arlington, Arlington, Va.

33
  1. Rates are for hospitals with either at least 3,500 total deliveries in 2014 or 1,000 low-risk births in either 2014 or the 12-month period ending in June 2015. 
  2. Composite of Las Palmas Medical Center (38 percent) and Del Sol Medical Center (36 percent).
  3. Composite of Methodist South Hospital (30 percent) and Methodist Le Bonheur Germantown Hospital (37 percent).
  4. Composite of Mainland Medical Center (44 percent) and Clear Lake Regional Medical Center (35 percent).
  5. Composite of Metropolitan Methodist Hospital (37 percent) and Methodist Hospital & Methodist Children's Hospital (33 percent).
  6. Composite of Jackson Memorial Hospital (40 percent), Jackson South Community Hospital (28 percent), and Jackson North Medical Center (30 percent).


How We Rate Hospitals on C-Sections
Consumer Reports compares hospitals on C-section rates for first-time mothers who don’t deliver prematurely ​and who are pregnant with a single baby in the proper position for delivery. ​Lower C-section rates earn higher scores. The data do not include information on some factors that may increase C-section risk, such as pregnancy-related high blood pressure, diabetes, obesity, or other chronic diseases. The data come from the Leapfrog Group as well as from the California Maternal Quality Care Collaborative, as provided by the California Healthcare Assessment and Reporting Task Force. We rate hospitals with at least 30 low-risk deliveries in either 2014 or the 12-month period ending June 2015. Hospitals submit data to Leapfrog voluntarily. Hospitals that score low on this measure may score well on other measures, such as preventing infections or readmission. Read more about how we rate hospitals.
 

Large U.S. Hospitals With Low C-Section Rates

There were 165 hospitals in the U.S. with C-section rates for low-risk deliveries of 18.4 percent or lower. Hospitals with rates below that level earned our top score. Nineteen of them were hospitals that had a high volume of deliveries.

Hospital Name

C-section Rate
(First-Time Mothers, Low-Risk Deliveries)1

Crouse Hospital, Syracuse, N.Y.11
Yuma Regional Medical Center, Yuma, Ariz.12
Memorial Medical Center, Springfield, Ill.12
Utah Valley Regional Medical Center, Provo, Utah13
Lovelace Women's Hospital, Albuquerque, N.M.13
Bakersfield Memorial Hospital, Bakersfield, Calif.15
University of Alabama Hospital, Birmingham, Ala.15
New Hanover Regional Medical Center, Wilmington, N.C.16
Park Nicollet Methodist Hospital, St. Louis Park, Minn.16
Bon Secours St. Mary's Hospital, Richmond, Va.17
Northwestern Memorial Hospital, Chicago, Ill.17
Kaiser Permanente Roseville Medical Center, Roseville, Calif.17
TMC HealthCare, Tucson, Ariz.17
Meriter UnityPoint Health, Madison, Wisc.17
San Joaquin Community Hospital, Bakersfield, Calif.17
JPS Health Network, Fort Worth, Texas17
WakeMed Raleigh Campus, Raleigh, N.C.18
Piedmont Fayette Hospital, Fayetteville, Ga.18
McKay-Dee Hospital Center, Ogden, Utah18
  1. Rates are for hospitals with a minimum 3,500 total deliveries in 2014 or 1,000 low-risk births in 2014 or the 12-month period ending in June 2015. 

The Challenge of Voluntary Reporting

Consumer Reports does not have C-section rates for more than half of the estimated 3,000 U.S. hospitals that deliver babies. That’s because hospitals are not required to publicly report that information, and many choose not to. (The Joint Commission, a hospital accrediting organization, has C-section rates for hospitals with more than 300 births each year, but does not make that information public.)

Particularly notable in their absence are 24 hospitals with more than 5,000 births. We contacted the three hospitals in that group with the most births—New York-Presbyterian Hospital in New York City, Magee-Womens Hospital of UPMC in Pittsburgh, and Memorial Hermann Northwest Hospital in Houston—for comment. None provided one.

“You have to give credit to the hospitals that report their data, even the hospitals that are lower performers,” says Leah Binder, chief executive officer of the Leapfrog Group, the nonprofit organization that collects and reports the data in most of the country. “It’s the hospitals that don’t report that you have to wonder about.” Binder notes that hospitals do not have to pay the Leapfrog Group when they report data.

Large Hospitals That Don’t Report C-Section Rates

The hospitals below all reported delivering at least 5,000 babies in 2014 but did not share their C-section rates with the Leapfrog Group. (Hospitals are listed alphabetically, within states. Note that an earlier version of this chart included CHRISTUS Santa Rosa Health System. It has been removed because it no longer has 5,000 births a year.)

The Danger of Unnecessary C-Sections

There are times when a surgical birth is the safest option. For example, an emergency C-section can be lifesaving if the placenta blocks the cervix, a condition called placenta previa. And it can sometimes make sense to schedule a C-section when, for example, the fetus isn’t properly positioned for birth. Cesareans can also be necessary if the mother has uncontrolled high blood pressure or diabetes, or when she is pregnant with twins, triplets, or other multiples.  

But when C-sections aren’t medically indicated, they may be more likely to harm mothers and babies than to help them. “As the cesarean rate went up from 1995 to 2007, we didn’t see a decrease in neonatal mortality in our country,” says Caughey, who helped write the new ACOG/SMFM recommendations. “In fact, if anything, we started to see an increase in maternal mortality.”

Harvard’s Shah points out that C-sections are major surgery, with all of the risks of any hospital procedure. “Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis to hemorrhage to organ injury,” he says.

Life-threatening complications are rare whether babies are born vaginally or by C-section. But women with low-risk pregnancies undergoing their first C-section were three times more likely to die or suffer serious complications—such as blood clots, heart attack, and major infections—compared with women delivering vaginally, according to a 14-year analysis of more than 2 million women in Canada published in 2007 and cited by the ACOG guidelines.

Another reason to avoid an unnecessary C-section: It multiplies the chance that a woman’s future births will also be delivered that way. “Right now in the U.S., if you get a C-section the first time, you have a 90 percent chance of getting another one the second time,” Shah says.

And while some may assume that C-sections are easier on mothers than vaginal births, research shows that it usually takes women longer to recover after the surgery.

Vaginal delivery for low-risk pregnancies may also be better for babies. They are less likely to suffer breathing problems and more likely to be breastfed, perhaps because it’s easier to get breastfeeding going when mothers are not recovering from major surgery.

Finally, C-sections cost almost 30 percent more than vaginal births. The average cost for a C-section in the U.S. today is $15,772, compared with $12,340 for a vaginal birth, though costs vary by as much as $10,000 across the U.S., according to Guroo.com.  

Why C-Section Rates Are So High

Much of the conventional wisdom for why rates have increased points to mothers—but that conventional wisdom doesn’t bear out, Shah says. “Some people say moms are older, there’s more diabetes, there’s more hypertension, there’s more obesity, there’s more IVF, there’s more twins—but all of that collectively only explains a small amount of the increase over time," he says.

Neither does patient demand appear to be behind the rates. Less than 1 percent of 1,314 new mothers actually asked for a C-section without a medical reason for it, according to a survey conducted by Childbirth Connection, part of the nonprofit National Partnership for Women and Families, that focuses on improving maternity care in this country. Of the 252 women in that survey who had a C-section, only one had requested it without a medical reason.

In the U.S. far fewer babies are born on holidays such as the Fourth of July or days around Thanksgiving or Christmas, we found when we examined three year's worth of data on births compiled for us by the Centers for Disease Control and Prevention. That occurs partly because hospitals tend to schedule C-sections and inductions for when they are well staffed, Shah explained.

Another major problem is that many doctors intervene because they think that labor is moving too slowly and that longer labors lead to complications, says Amy Romano, a certified nurse midwife (CNM) and senior vice president of clinical programs for Baby+Company, a network of midwife-led maternity clinics based in North Carolina. But those assumptions about how long labor should take are based on information gathered in the 1950s, Romano says.

The new ACOG guidelines help clear up when healthcare providers should act and when they should be patient and let nature take its course. But the previous absence of solid, up-to-date guidelines has meant that a hospital’s culture drives up the number of cesareans, Caughey says. “Changing that takes time,” he notes. “That appears to be starting to happen, but will be a slow transformation."

How Hospitals Can Improve

Indeed, lowering C-section rates can take years of hard work, according to Robert Silverman, M.D., chief of the Department of Obstetrics and Gynecology at Crouse Hospital in Syracuse, N.Y. His hospital had the lowest C-section rate for low-risk pregancies among hospitals with at least 3,500 births in our Ratings, at just 11 percent.

"We have spent literally decades on educating the physicians at our institution about really good prenatal care," Silverman says. "Everything we can do to prevent that first C-section from occurring, we try to do."

To learn what you can do, see our article "How to Avoid a C-Section Procedure."


Editor's Note: This report is supported in part by the California HealthCare Foundation, based in Oakland, Calif.