White Coat Notes

Why caesarean birth rates differ at area hospitals

June 7, 2010

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Caesarean delivery rates have been rising across the country for a decade, and state public health specialists are trying to understand why the rates are higher at some Massachusetts hospitals than others.

Raw numbers of caesarean births, meaning rates that don’t take into account risk factors for mothers and babies or complications during labor and delivery, show that five community hospitals, including one that serves high-risk women and newborns, had the highest proportion of caesareans. The five lowest rates were also at community hospitals. Teaching hospitals with high-level neonatal intensive care units, where one might expect women with high-risk pregnancies to go, are closer to the state average of 34.4 percent.

Dr. Lauren Smith, medical director of the Massachusetts Department of Public Health, said that while there is no magic number for the percentage of births that should be caesarean deliveries, state analysts want to know why rates differ so markedly. A separate analysis based on births from 2004 through 2006 found that when hospitals were divided into three groups based on the complexity of obstetrical care they provided, the caesarean rates varied widely within those groups. Risk was taken into account after looking at birth certificates and other records.

“There are a complex array of factors that contribute in each individual case to whether or not a woman delivers vaginally or via caesarean,’’ Smith said in an interview. “And some of those are factors are at the hospital level, such as how do they organize the staffing of their labor and delivery units, what are the resources that might be available, . . . is it a teaching facility, are there residents or attending [physicians], how many delivery rooms or operating rooms do they have.’’

Dr. Paul Allen, vice president of medical affairs at Holy Family Hospital in Methuen, said the decision is made between the patient and the physician. Holy Family had the highest caesarean rate in the state, at 47.4 percent.

“It’s not a number that we place a lot of emphasis on,’’ he said. “More important is the safety and quality of the outcome and if you look at the infant mortality rate at the hospital, we’re really pleased with it. That’s the number we are most concerned with.’’ In 2008, that mortality rate was zero.

At Melrose-Wakefield Hospital, which had the second highest caesarean rate, Dr. Bernard Logan said the hospital doesn’t have an answer for its 45.7 percent rate. “We do review the cases,’’ he said. “We have excellent outcomes with healthy babies and healthy mothers.’’

About 2 percent to 3 percent of the rate may reflect the hospital’s policy of referring to teaching hospitals those women who have had caesareans but want to deliver their next baby vaginally, said Logan, who is chairman of obstetrics and gynecology at the hospital’s parent company, Hallmark Health.

South Shore Hospital’s third-highest rate of 43.9 percent is explained by the needs of its patients, said Dr. Veronica Ravnikar, chairwoman of obstetrics and gynecology. “We have a Level III [neonatal intensive care unit] staffed by Children’s Hospital pediatricians and neonatololgist and we have a Level III maternity center in which we take care of women who are high risk on the South Shore. Those two things distinguish us.’’

South Shore also has an affiliation with Brigham and Women’s Hospital that brings patients who have had fertility treatments to the Weymouth hospital. Those women tend to be older and are more likely to have multiple births, both of which raise the chances for a caesarean, Ravnikar said.

The caesarean rate was 35.2 percent at the Brigham, where its 8,115 total births leads the state.


Underestimating hours worked by residents

Most Americans believe residents — doctors in training who work at teaching hospitals — put in far fewer hours than they actually do, a new survey has found. And people also told the pollsters they would want to know if the doctor treating them has been on the job for 24 hours so they could ask for a different caregiver.

Dr. Charles Czeisler of Brigham and Women’s Hospital and his colleagues report on a telephone survey that asked people how many hours they thought resident physicians worked. Most of the 1,200 respondents thought the residents worked no more than 12-hour shifts and no more than 80 hours a week. In reality, resident physicians are allowed to work up to 30 consecutive hours, twice a week, under guidelines set by the Accreditation Council on Graduate Medical Education. Residents are also limited to working an average of 80 hours a week over four weeks, but the hours any one week could be higher. The study appears in in the online journal BMC Medicine. The margin of error was plus or minus 2.8 percentage points. E.C.

Be careful when using sunscreen with DEET

When it comes to one kind of sunscreen lotion, there can be too much of a good thing, a top Massachusetts health official cautions.

Some sunscreens are combined with a widely used mosquito-repellent called DEET to protect against the sun’s rays and bugs’ bites all at once. But Suzanne Condon, director of the state’s Bureau of Environmental Health, urged careful use of the combination product, especially if you’re going to need to repeatedly slather on protection against the sun.

While reapplying sunscreen is a good idea, it’s not necessary to repeatedly douse yourself with DEET.

“You don’t want to keep applying pesticide when the real goal is to prevent the child from being sunburned’’ said Condon.

The US Centers for Disease Control and Prevention is against using the combination product and recommends wearing long sleeves and pants to avoid sun exposure and insect bites. Bug repellent can be applied to clothing rather than directly on the skin. STEPHEN SMITH


Percent of all births, unadjusted for risk factors. The state average was 34.4.

Holy Family Hospital, Methuen: 47.4

Melrose-Wakefield Hospital, Melrose: 45.7

South Shore Hospital, Weymouth: 43.9

MetroWest Medical Center-Framingham Union Hospital: 41.8

Signature Healthcare Brockton Hospital, Brockton: 41.1


Heywood Hospital, Gardner: 16.2

North Adams Regional Hospital, North Adams: 18.2

Tobey Hospital, Wareham: 19.1

Holyoke Medical Center, Holyoke: 21.6

HealthAlliance Hospital- Leominster Campus: 22.2

SOURCE: Massachusetts Department of Public Health, data for 2008

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