Having a Baby in California?

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 low-risk births, set by the Department of Health and Human Services, is 23.9 percent or lower. 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," Main says. "But for those deliveries hospitals should be aiming even lower," he says.

Yet six in 10 California hospitals had C-section rates above the target for low-risk births; about one in 10 had C-section rates above 33.3 percent, earning those hospitals our lowest Rating.

Of the nearly 250 hospitals in our Ratings, the 10 listed below had the most low-risk deliveries in the state. None earned a top score, and only three—Pomona Valley Hospital Medical Center in Pomona, California Pacific Medical Center in San Francisco, and Alta Bates Summit Medical Center in Berkeley—had rates lower than the national target of 23.9 percent.

Making a hospital's C-section rate public not only helps families choose a hospital, but can also motivate hospitals and doctors to change their practices. "There's a lot of denial of the problem of high C-section rates and we need to overcome it," says Main, who notes that simply having the data is an important first step in correcting the problem.

"Nobody wants to be an outlier," says Colleen McNally, M.D., chief medical officer at Sharp Mary Birch Hospital for Women and Newborns in San Diego. That hospital delivered the most babies in California in 2014—and had a C-section rate of nearly 34 percent among low-risk births, earning it our lowest score.

Sharp is using data from the California Maternal Quality Care Collaborative to make changes. "We were able to look at individual physicians' rates," she says, and "we knew we had an issue."

The hospital is now working with providers who have high rates, helping them to encourage vaginal birth by, for example, allowing women to labor longer before resorting to a C-section. In addition, the hospital plans to use a toolkit developed by CMQCC to help hospitals get their low-risk C-section rates below 23.9 percent within five years.  

"It was important to educate both the nurses and the physicians," McNally says. "It was really important that we were all on the same page."

It's also vital to involve patients. "We provided a lot of education to patients about the stages of labor," McNally says, explaining that mothers do much better when they stay at home longer—where they can shower, eat, and move around—and only come to the hospital when they enter active labor.

"Are we at the California ideal rate?" McNally says. "Not yet, but we're getting closer."

Officials at Memorial Hospital of Gardena say it too is working with CMQCC to track its performance against other hospitals. And the hospital has recruited a perinatologist—a specialist in caring for mothers and babies—to be on call 24/7 to consult with patients and obstetricians "to ensure the safest and best birthing outcomes for mothers and their newborns," says Kathy Wojno, R.N., CEO at the hospital.

The state of California is also taking steps that it hopes will motivate hospitals to lower their C-section rates. For example, Covered California, the state's Affordable Care Act health insurance exchange, recently proposed that all plans listed on the exchange must contract with hospitals that meet certain standards, including low C-section rates.

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How to Avoid a C-Section Procedure
What to Do If You Need a Cesarean Section
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Of the nearly 250 California hospitals in our Ratings, 26 had C-section rates above 33.3 percent for low-risk deliveries. Hospitals with rates above that level received our lowest score. Twelve of them were hospitals with at least 200 low-risk deliveries in 2014.

Of the nearly 250 California hospitals in our Ratings, 16 had C-section rates at or below 18.4 percent, earning them our top score. Twelve of them were hospitals with at least 200 low-risk deliveries in 2014.

While knowing your hospital's C-section rate is key, it doesn't tell you the whole story.

"You also want to know it's a safe place," says Main, at the California Maternal Quality Care Collaborative. One key indication of that: how many women undergoing a C-section develop an infection at their incision after the operation.

Two other important indicators: how often women undergo episiotomies, and the percentage of mothers who breastfeed their babies while they are in the hospital. "We need to focus on changing the culture to perform fewer interventions like episiotomies and greater support for natural functions like breastfeeding," Main says.

Episiotomies can be necessary in the case of a delivery that requires help from forceps or a vacuum, or if the baby is descending too quickly for the tissues to stretch. But often, routine episiotomies don't help and are associated with several problems, including more damage to the area near the rectum and a longer healing period, according to a 2009 Cochrane review of 8 studies involving more than 5,500 women.

And breastfeeding is best for most babies, according to the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention. Breast milk provides the best nutritional mix, is easier to digest, and has been linked to a reduced risk of ear infections, diarrhea, respiratory illnesses, allergies, and sudden infant death syndrome. For mothers, breastfeeding soon after giving birth triggers the release of a hormone that helps the uterus to contract, and may reduce the amount of bleeding you have. It may also help you lose any weight you gained during your pregnancy, and possibly reduce your risk of breast and ovarian cancers.

Click on the map below to use our interactive tool showing how hospitals compare on C-sections, infections, breastfeeding, and episiotomies.