Cesarean sections: increasing and profitable

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The cesarean section is designed to help deliver babies through problem pregnancies, reducing the danger of childbirth for babies and their mothers. But it turns out the increasing popularity of c-section deliveries might be having an unintended consequence.

Earlier this year, an analysis showed that pregnancy-related deaths are down significantly around the world – that’s the good news. The bad news is that here in the US, pregnancy-related deaths are not down, but up -- to 17 deaths per 100 thousand women. And in California, that number is even higher -- 19 deaths per 100 thousand women.

KALW’s Nathanael Johnson is working on an in-depth report on possible links between c-sections and maternal mortality. He found that whether or not you have the procedure largely depends on which hospital you go to. KALW's Hana Baba sat down with Nate, and asked him what he found.

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NATHANAEL JOHNSON: I guess the biggest take away for me is that this big variation from one hospital to another probably indicates that unnecessary medical care is happening. People are doing treatments and surgeries that don’t need to be done. And the scary thing about that is cesarean section is not a small procedure. We know, that its completely uncontroversial that the more c-sections we do, the more women will die, and the more injuries will occur.

Where it gets controversial is where you look in the moment, where you’re doing one, is it safer for the woman? Is it safer for the infant? The science there is very hazy, but when you look over the course of a woman’s lifespan, and the number of children that she’ll have, not just in that moment, it’s completely uncontroversial that it gets more dangerous to do more of them.

HANA BABA: So, how did you start off conducting your research?

JOHNSON: Well, I wanted to see if there were c-sections that were being done that were unnecessary. We know that the cesarean section rate has gone up dramatically in this country. And, we know that there are probably some good reasons for that. Women are more obese, there’s more women giving birth later in life, but I wanted to know: are there c-sections that are happening beyond that, that are happening for no good reason?

So to look at that, instead of looking at the rate across time, I said let’s look at the rate in between hospitals. Because, if two hospitals have a similar population, you shouldn’t have older, sicker, fatter women at one hospital, and not at the other. And we found a tremendous variation in the cesarean section rates between hospitals around California.

BABA: Between what kind of hospitals?

JOHNSON: Well, between all kinds of hospitals. Specifically, one of our findings was that if you averaged out the cesarean rates for non-profit hospitals, and compared that with the average cesarean rates for for-profit hospitals, there was s significant difference there. So a woman has about a 15% greater likelihood of getting a cesarean section if she’s walking into a for-profit hospital in California. That’s the average.

BABA: Can you explain to me which hospitals are considered for-profit and which ones are non-profit?

JOHNSON: Right. So, that’s something that’s confusing because most people think of the non-profit as maybe the ones where you might go for charity care. But most hospitals in California -- 208 in our data set -- were non-profit, as opposed to 48 that are for-profit. So when we’re looking at non-profit hospitals, we’re just looking at all the hospitals that don’t make money for their investors in California, and those include most of the hospitals that you think of as the crème de la crème in California.

BABA: Kaiser?

JOHNSON: Kaiser, Sutter, Mercy Hospitals.

BABA: Do you know how much money a hospital makes per c-section?

JOHNSON: Well, its very opaque. Hospitals in this country and the insurance system make everything very confusing, and a lot of this information isn’t available to the public. But there have been some analyses done, and it looks like hospitals almost double their profits when they convert a vaginal birth to a cesarean section. So they make about a thousand more dollars -- this is on average in California, per birth. And so there is a financial incentive there. The question is, are there enough barriers there between the people earning the money and the people making the decision, to prevent that from affecting it?

BABA: I never understood why a c-section would cost more than a vaginal birth. Is it because the anesthesiologist is there? Is it the doctors and the OR room? Because a natural birth takes more time, the nurses are there for longer, they check on you for longer, you’re occupying that bed for a longer period of time. So it would seem that it would be more expensive.

JOHNSON: It would seem so. And in a rational medical system, it might be. But we have a system that bills by procedure. It doesn’t bill by effort, it doesn’t bill by how good your outcomes are. It bills by the thing that you can claim, and if you can claim surgery, anesthesia, use of the OR room, all these things add up; whereas for natural birth, there’s one line -- there’s assisted delivery. It’s the one line on the billing. And so a doctor gets paid the same amount whether she spends 48 hours working with a woman to get the baby delivered vaginally, or whether she spends one hour doing it surgically.

BABA: Did you find that it really boils down to that doctor-patient decision, or, since you found such disparity between for-profit and non-profit hospitals, does the hospital have a say?

JOHNSON: That’s really interesting. This for-profit, non-profit disparity is significant enough that you can’t ignore it. The tricky thing is that doctors are making these decisions with the patients, and the doctors often don’t work for the hospitals. So, if the hospitals are influencing that decision, they’re not doing it by having an administrator walking into the delivery room and saying, "look, we can really make another thousand dollars here if you just do a c-section." They’re doing it perhaps indirectly, through the way the hospital is set up. It may be just a little bit of pressure to be, like, "look, we have three more people coming in, we really need to clear these beds." And if you’ve got a woman that’s taking a really long time in labor, that could be another 24 hours, whereas the c-section is done in the next hour.

BABA: How can it be solved? Where, and at what level? Do you start with the doctors? Do you start at the hospital level? Do you start at a state level, with policy?

JOHNSON: It’s being solved at a lot of levels right now, and it will be interesting to see if this has any impact. My sense is that the pendulum has reached the apex of its swing, and it may start swinging back now. We’ve hit historic highs for cesarean section every year, at this point. And now, the major mainstream medical groups in America are really starting to get worried about this, and are saying: how do we put pressure? Where do we put pressure? And how do we safely bring this rate down? So there are really smart people looking at the policy level, there are doctors who are looking at the techniques that they can use to do deliveries, to do vaginal birth after caesarian, so that some of those women who initially had those caesarians don’t automatically have to have another. So all different sectors are realty pushing forward with this. And it will be interesting to see if that does turn the pendulum, or if we just have so much momentum in this direction that it will continue moving.

You can find Nate Johnson's reports on maternal mortality here.

And here's Crosscurrents interview with Nate on maternal mortality, from earlier this year.