Women are more likely to have a Caesarean section at a for-profit (private) hospital than at a nonprofit (public) one.
That’s one of the troubling findings from an investigative project published Sunday by California Watch, an independent team of investigative journalists funded by the nonprofit Center for Investigative Journalism.
The reporters analyzed a database of state birthing records from 253 California hospitals. They then narrowed the births to those deemed to be least likely to require C-sections (a single, full-term fetus, positioned head down). After further adjusting the data for the mother’s age (older women tend to have more complicated pregnancies), they found that the average C-section rate for these low-risk births was 16 percent at nonprofit hospitals compared to 19 percent at for-profit ones.
“That may seem like a small percentage gap to the casual observer,” wrote California Watch reporter Nathanael Johnson, “but medical experts consider it a significant difference. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital.” The higher C-section rates were found, he added, “at hospitals catering to all ethnic groups and economic classes. And there was no correlation between C-section rates and the percentage of a hospital’s business from low-income or indigent patients receiving Medi-Cal, the state’s Medicaid program.”
Why the difference? A hospital’s bottom line — profit margin — may, of course, be a factor. As Johnson points out, hospitals on average make about 80 percent more profit from an uncomplicated C-section as from a comparable vaginal birth.
Physician patience (or, rather, lack of it) may also play a role. As Johnson reports, doctors and hospitals often cite “failure to progress” as the reason for C-sections, but many nurses call it by another name: “failure to wait.”
Johnson provides this telling anecdote about a nonprofit hospital, Riverside County Regional, which has one of California’s lowest C-section rates (9 percent):
[The hospital’s vice chairman of obstetrics, Guillermo] Valenzuela attributes his hospital’s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.
By contrast, most doctors [at hospitals that don’t use this shift model], who must be there when the baby arrives to make their fee, face a dilemma unknown to shift workers: either wait hours for a vaginal delivery or perform a C-section.
California’s Kaiser Permanente hospitals also use the shift-work model, reports Johnson. He quotes a doctor who is remarkably candid about why this model results in fewer C-sections:
“You are sitting in labor and delivery for 12 hours and she’s barely making progress, and your family is yelling at you, wondering when you are going to come home,” [Dr. Tracy] Flanagan said. “There’s tremendous pressure. In addition, you know that you will get paid the same or more for doing a C-section. Our medical system makes it hard to do the right thing. That’s a big reason I moved over to Kaiser.”
C-sections in Minnesota
Earlier this year, the Star Tribune ran a two-part series (here and here) on the controversy surrounding our own state’s rate of C-sections. As reporters Josephine Marcotty and Chin May Lee pointed out, Minnesota’s C-section rate was 26 percent in 2007, the latest year for which data is available. That compares with a national rate of 36 percent (a huge leap from the 5 percent rate of 1970). The World Health Organization recommends a C-section rate of no more than 15 percent. The second article in the Strib series features St. Joseph’s Hospital in St. Paul, which has one of the lowest C-section rates (13 percent) of any hospital in the country.St. Joseph’s administrators attribute their hospital’s low rate to a reliance on midwives, who deliver 40 percent of the babies born there.