Persistent problem: High C-section rates plague the South

All along, Julia Maeda knew she wanted to have her baby naturally. For her, that meant in a hospital, vaginally, without an epidural for pain relief.

This was her first pregnancy. And although she is a nurse, she was working with cancer patients at the time, not with laboring mothers or babies. "I really didn't know what I was getting into," said Maeda, now 32. "I didn't do much preparation."

Her home state of Mississippi has the highest cesarean section rate in the U.S. — nearly 4 in 10 women who give birth there deliver their babies via C-section. Almost two weeks past her due date in 2019, Maeda became one of them after her doctor came to her bedside while she was in labor.

"'You're not in distress, and your baby is not in distress — but we don't want you to get that way, so we need to think about a C-section,'" she recalled her doctor saying. "I was totally defeated. I just gave in."

C-sections are sometimes necessary and even lifesaving, but public health experts have long contended that too many performed in the U.S. aren't. They argue it is major surgery accompanied by significant risk and a high price tag.

Overall, 31.8% of all births in the U.S. were C-sections in 2020, just a slight tick up from 31.7% the year before, according to the latest data from the Centers for Disease Control and Prevention. But that's close to the peak in 2009, when it was 32.9%. And the rates are far higher in many states, especially across the South.

These high C-section rates have persisted — and in some states, such as Alabama and Kentucky, even grown slightly — despite continual calls to reduce them. And although the pandemic presented new challenges for pregnant women, research suggests that the U.S. C-section rate was unaffected by covid. Instead, obstetricians and other health experts say the high rate is an intractable problem.

Some states, such as California and New Jersey, have reduced their rates through a variety of strategies, including sharing C-section data with doctors and hospitals. But change has proved difficult elsewhere, especially in the South and in Texas, where women are generally less healthy heading into their pregnancies and maternal and infant health problems are among the highest in the U.S.

"We have to restructure how we think about C-sections," said Dr. Veronica Gillispie-Bell, an OB-GYN who is medical director of the Louisiana Perinatal Quality Collaborative, a group of 43 birthing hospitals focused on lowering Louisiana's C-section rate. "It's a lifesaving technique, but it's also not without risks."

She said C-sections, like any operation, create scar tissue, including in the uterus, which may complicate future pregnancies or abdominal surgeries. C-sections also typically lead to an extended hospital stay and recovery period and increase the chance of infection. Babies face risks, too. In rare cases, they can be nicked or cut during an incision.

Although C-sections are sometimes necessary, public health leaders say these surgeries have been overused in many places. Black women, particularly, are more likely to give birth by C-section than any other racial group in the country. Often, hospitals and even regions have wide, unexplained variations in rates.

"If you were delivering in Miami-Dade County, you had a 75% greater chance of having a cesarean than in northern Florida," said Dr. William Sappenfield, an OB-GYN and epidemiologist at the University of South Florida who has studied the state's high C-section rate.

Some physicians say their rates are driven by mothers who request the procedure, not by doctors. But Dr. Rebekah Gee, an OB-GYN and former secretary of the Louisiana Department of Health, said she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home.

She led several initiatives to improve birth outcomes in Louisiana, including leveling Medicaid payment rates to hospitals for vaginal deliveries and C-sections. In most places, C-sections are significantly more expensive than vaginal deliveries, making high C-section rates not only a concern for expectant mothers but also for taxpayers.

Medicaid pays for 60% of all births in Louisiana, according to KFF, and about half of all births in most Southern states, compared with 42% nationally. That's one reason some states — including Louisiana, Tennessee, and Minnesota — have tried to tackle high C-section rates by changing how much Medicaid pays for them. But payment reform alone isn't enough, Gee said.

"There was a guy in central Louisiana who was doing more C-sections and early elective deliveries than anyone in the U.S.," she said. "When you have a culture like that, it's hard to shift from it."

Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, said many hospitals and doctors don't even know their C-section rates. Sharing this data with doctors and hospitals — and making it public — made some providers uncomfortable, she said, but it ultimately worked. New Jersey's C-section rate among first-time, low-risk mothers dropped from 33.1% in 2013 to 26.7% six years later once the state began sharing this data, among other initiatives.

The New Jersey Health Care Quality Institute, and other groups like it around the country, focuses on reducing a subset of C-sections called "nulliparous, term, singleton, vertex" C-sections, or surgeries on first-time, full-term moms giving birth to a single infant who is positioned head-down in the uterus.

NTSV C-sections are important to track because women who have a C-section during their first pregnancy face a 90% chance of having another in subsequent pregnancies. Across the U.S., the rate for these C-sections was 25.9% in 2020 and 25.6% in 2019.

Dr. Elliott Main, a maternal-fetal specialist at Stanford University and the medical director of the California Maternal Quality Care Collaborative, co-authored a paper, published in JAMA last year, that outlines interventions the collaborative took that lowered California's NTSV C-Section rate from 26.0% in 2014 to 22.8% in 2019. Nationally, the rate was unchanged during that period.

Allowing women to labor for longer stretches of time before resorting to surgery is important, he said.

The cervix must be 10 centimeters dilated before a woman gives birth. The threshold for "active labor" used to be when the cervix was dilated at least 4 centimeters. In more recent years, though, the onset of active labor has been changed to 5 to 6 centimeters.

"People show up at the hospital too early," said Toni Hill, president of the Mississippi Midwives Alliance. "If you show up to the hospital at 2 to 3 centimeters, you can be at 2 to 3 centimeters for weeks. I don't even consider that labor."

Too often, she said, women at an early stage of labor end up being induced and deliver via C-section.

"It's almost like, at this point, C-sections are being handed out like lollipops," said LA'Patricia Washington, a doula based in Jackson, Mississippi. Doulas are trained, nonmedical workers who help parents before, during, and after delivery.

Washington works with a nonprofit group, the Jackson Safer Childbirth Experience, that pays for doulas to help expectant mothers in the region. Some state Medicaid programs, such as New Jersey's, reimburse for services by doulas because research shows they can reduce C-section rates. California has been trying to roll out the same benefit for its Medicaid members.

In 2020, when Julia Maeda became pregnant again, she paid out-of-pocket for a doula to attend the birth. The experience of having her son via C-section the previous year had been "emotionally and psychologically traumatic," Maeda said.

She told her OB-GYN that she wanted a VBAC, short for "vaginal birth after cesarean." But, she said, "he just shook his head and said, 'That's not a good idea.'"

She had VBAC anyway. Maeda credits her doula with making it happen.

"Maybe just her presence relayed to the nursing staff that this was something I was serious about," Maeda said. "They want you to have your baby during business hours. And biology doesn't work that way."