Patient Care

Rise in C-Sections Tax Hospitals' Resources

By Laura Putre

Increased costs, longer stays and risks to patients get insurers’ attention

At Women and Infants Hospital of Rhode Island, CEO Constance Howes has seen a dramatic rise in babies delivered by C-section. In the mid-1990s, the rate was 17 percent, but since then it has nearly doubled to 32.4 percent. The shift has “definitely stressed our capacity,” Howes says. “With the increase in C-sections, patients stay twice as long, so we need twice as many rooms for our postpartum patients.”

Partly because of the resulting space crunch, the hospital is planning a $78.6 million addition. Along with a new neonatal intensive care unit, the five-story building will include 30 additional postpartum rooms.

According to the Agency for Healthcare Research and Quality, the number of Caesareans nationally climbed 38 percent between 1995 and 2005. The increase stems from two factors. The first is a rise in obese pregnant women, “and with that increase there are more women at higher risk,” Howes says. “That leads to potentially more Caesareans.”

The other factor is the growing reluctance of physicians to perform vaginal births after a previous Caesarean. According to the Centers for Disease Control and Prevention, the VBAC (vaginal births after Caesarean) rate fell 67 percent from 1996 to 2004.

In 1999, the American College of Obstetricians and Gynecologists issued more restrictive guidelines for VBACs because some studies showed an increased, yet still minimal, risk of uterine rupture.

“Clearly there’s a concern of litigation,” Howes says. “There are hospitals with smaller obstetrics services that are not doing them at all.”

The number of elective Caesareans is also climbing, says Alan Peaceman, M.D., chief of maternal fetal medicine at Prentice Women’s Hospital, part of Northwestern Memorial Hospital in Chicago. “More and more women are walking in and asking for C-sections,” he says, and because “hospitals perceive more risk with vaginal delivery [they] are not resisting the requests.”

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Lynn Taylor, risk manager and president of Healthcare Risk Solutions, says that in some New York City hospitals, C-section rates hover around 40 percent. “We have a very high-income, highly educated group of consumers and those moms sometimes ask for a C-section on demand,” Taylor says. “They don’t want to go through child labor and they want to know the date they’re going to have the baby so they can be in control of the circumstances. We’re also in a very litigious region of the country, so [if there’s] any concern about a heightened risk of the well-being of the infant, frequently the physician will say, ‘Let’s get this patient in for a C-section.’ Some of this is fear of litigation, and the perception that doing a C-section will ensure the baby’s not harmed.”

Increasingly, Taylor says, private insurers recognize the risks of C-sections, including infection and deep-vein thrombosis.

“What we may see over time is insurers starting to intervene and say, ‘No, doctor. We’ve looked at your rates and they’re way too high. The numbers are not valid and you will not be permitted to be reimbursed for C-sections in the future.’ That will clearly change the practice.”

This article first appeared in the April 2008 issue of H&HN magazine.

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