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The 10 Most Cesarean-Happy States in the U.S.


Centers for Disease Control and Prevention (CDC) has been gathering data on total cesarean rates for several decades. Total cesarean (or C-section) rates, which are the total number of cesareans divided by all live births x 100, don’t tell much of a story beyond overall trends and geographic differences in use of the cesarean.


Now, CDC publishes low risk cesarean rates, also known as NTSV cesarean rates.

N= Nulliparous, or first-time moms

T= Term pregnancy

S= Singleton (not twins, triplets or more)

V= Vertex, meaning the baby was head-down


The Leapfrog Group recently published hospital NTSV c-section rates for their participating hospitals.


So where is it hardest to get a vaginal birth in a hospital? Check out this slideshow of the 10 Most Cesarean-Happy States in the U.S. and see if your state is included.


Based on 2014 preliminary data




Tennessee had a 28.3% low risk c-section rate in 2014, up from 26.8% in 2013. The state’s total cesarean rate was 33.7%. The most recent VBAC data for Tennessee shows that 10.7% of women with a previous cesarean gave birth vaginally in 2013. 

All cesarean rates by state | VBAC rates       NEXT>






Chattanooga, Tennessee Skyline” by Imilious 




Top 10 Reasons a Birth Center Birth is Not For You




 (…and Why You Might Be Wrong!)

Guest post by Poppy Daniels, MD

  1. “A hospital is the safest place to give birth.” The American Congress of Obstetricians and Gynecologists (ACOG) has stated that a hospital-based or freestanding accredited birth center is a reasonable option for low risk women.

  2. “What if an emergency happens, a hospital is prepared for emergencies?” Birth centers are typically equipped with oxygen, IV fluids, medications to slow bleeding and providers are trained in CPR and neonatal resuscitation. True emergencies are very rare, although most birth centers are located in close proximity to hospitals should a transfer become necessary. Most birth center transfers are non-emergent (mom develops risk factor during prenatal care, dysfunctional labor, maternal exhaustion, etc).

  3. “My insurance requires me to go to the hospital to give birth.” Insurance often covers birth center births. Since the cost of a birth center birth is approximately 50% less than a low risk hospital birth, you get more bang for your health care buck. Cost savings are significant for patients without insurance.

  4. “My husband, family, friends or in-laws would be upset if I didn’t deliver in the hospital.” Most people aren’t aware of the beautiful surroundings, safety features, and low cost of birth centers. Tours of facilities and researching your options can help you to determine if a birth center is a good fit for you. Remember, your birth is about YOU, not what makes other people feel better.

  5. “I’m not a hippie, why would I deliver at a birth center?” Increasing numbers of highly-educated, professional people choose to have their babies in a birth center as well as many non-professionals and non-hippies. With so much information available online, women of all kinds are seeking out high quality prenatal care and empowered birthing options.

  6. “I’m high risk, I can’t deliver at a birth center.” Some people ARE truly high risk (moms who have diabetes, hypertension or history of cesarean section*). However, each pregnancy is different and there are many women who would qualify for a birth center birth (miscarriages, infertility, advanced maternal age, etc.).

  7. “Isn’t continuous fetal monitoring better for my baby?” Continuous fetal monitoring has not been shown to be a benefit over intermittent fetal monitoring in low risk women.

  8. “The hospital has pediatricians for my baby.” Pediatricians don’t attend low risk births at the hospital. Birth center providers are trained in newborn assessment and resuscitation.

  9. “There are lots of people checking on me in the hospital.” Many women appreciate the midwifery model of care and the time spent during longer prenatal visits (30-60 minutes vs 10-15 minutes) as well as the continuity through birth and post-partum. Some families get annoyed with constant interruptions by multiple people in the hospital for vital signs, dietary, housekeeping, nursery or lab draws at 6 AM.

  10. “I can’t have an epidural in a birth center.” True. But you CAN have increased mobility to move around in labor: walking, standing, birth balls and birth tubs help provide many women pain relief in labor.


ACOG has acknowledged that birthing in a hospital-based or freestanding accredited birth center is a reasonable option for low risk pregnant women. They have recently released a statement with the American College of Nurse Midwives affirming evidence-based models of care and the need for collegial relations and collaboration between obstetricians and midwives.  (Joint Statement of Practice Relations Between Obstetricians and Gynecologists and Certified Nurse Midwives/Certified Midwives, Feb 2011, Reaffirmed by ACOG Executive Board July 2014)


Dr. Poppy Daniels is an OB/GYN who works with midwives at the Family Birth & Wellness Center in Springfield, MO, www.familybirth.com. You can follow her at “Dr. Poppy” on Facebook and @drpoppyBHRT on Twitter.



*Edit (8/11/2015): The author clarified this statement about history of cesarean section.If a woman has had a successful VBAC then her risk is less than a primary VBAC. The most risky situation is a woman who has a cesarean after a failed VBAC attempt. This is clear in the literature. It is not that people CANNOT do it. That is not the point. The point is that most birth centers are under a lot of scrutiny and in some states, laws that prohibit women who’ve had prior cesareans.”


Issue 9, July 2015


The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

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Wide Variation Found In Hospital Facility Costs For Maternity Stays Involving Low-Risk Childbirth

Childbirth is the leading cause of hospital admission in the United States, yet there has been little research on variation in hospital costs associated with childbirth.


The large variation in estimated facility cost for low-risk childbirths among hospitals suggests that hospital practices might be an important contributor to variation in cost and that there may be opportunities for cost reduction. The safe reduction of cesarean deliveries, increasing the coordination of care, and emphasizing value of care through new payment and delivery systems reforms may help reduce hospital costs and cost variation associated with childbirth in the United States.




Big Push: Hospitals Turn To ‘Laborists’ For Safer Deliveries

As a result, the two remaining obstetricians here no longer have to worry about being on call every other day because an obstetrician is always at the hospital.  “This gives my patients a safe passage for delivery,” said Dr. Albert French, 64, who has been delivering babies in Milford for 16 years.

But the change has also meant his patients sometimes may be delivered by a doctor they’ve never met before. “It’s a trade-off of familiarity for availability,” he said.




Health care pricing in Florida remains murky

When Maxxzandra Ford’s baby boy arrived in February, a number of unexpected hospital bills arrived with him.

“They don’t tell you how much the anesthesiologist is going to cost,” said Ford, who gave birth at St. Joseph’s Women’s Hospital in Tampa. “If you get an epidural or pain medicine, there’s an extra charge there.”

There were other surprise charges from doctors along the way, like $250 for each ultrasound.

Welcome to the mysterious world of health care pricing. Patients frequently receive medical services without knowing the cost — and remain in the dark until the bill arrives.

Sometimes even doctors don’t know how much procedures cost.




The Real Price of Having a Baby

The hospital where you give birth plays a huge role in how much you’ll pay out of pocket.

Which hospital parents pick to deliver their baby can have serious cost consequences, according to a new study.

Hospital costs for women who had no maternal or obstetric risk factors to complicate childbirth ranged from less than $2,000 to nearly $12,000, the analysis of discharge data found. The wide variation in cost means that for expectant parents, it can pay to shop around.




Record Number of Hospitals Commit to Transparency, but Some Still Struggle to Provide Consistently Safe, High-Quality Care

Last year, just over 1,500 U.S. hospitals voluntarily completed the Leapfrog Hospital Survey, the highest recorded participation to date.




The Anthem-Cigna Deal Raises A Big Question For The U.S. Insurance Business

This isn’t really the companies’ fault. In fact, a lot of them are now innovating in ways that could be good for patients in the long run. But here’s the fundamental disconnect: The insurance industry has failed at managing health care costs.




Out-of-network costs lurk even at in-network hospitals

“I called my insurance company and they gave me the song and dance about how this physician was a nonparticipating provider,” she said. “I said, ‘I went to your participating hospital. How does this make sense?’”

But she was told that the charge was legitimate and that she was on the hook for the bill.

Like Martin, millions of Americans get surprise bills from doctors who don’t participate with their health plan but who practice in hospitals that do.




Time to promote fairness and transparency in healthcare

According to an American Medical Association survey, doctors spend on average 20 hours a week filling out authorization paperwork for medications and tests — time better spent on caring for patients. With a shortage of health care providers nationwide and 12 million more Americans with health insurance, obstacles like these undermine the entire ACA system of care by discouraging providers committed to quality and efficiency from accepting insurance altogether.




Consumers are struggling to compare medical prices and find providers

The reality is health care costs are typically hidden and they vary significantly from provider to provider. Consumers have no safe place to find accurate information about prices and providers.




Infection prevention methods in US vary after cesarean delivery

A survey of U.S. academic centers revealed marked variability in the practices used to prevent infections after cesarean delivery.




Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports



Issue 8, June 13, 2015



The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

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An Increasing Number of American Mothers Are Using Midwives for Their Births - The Atlantic



Cesarean birth may raise baby’s risk of asthma, diabetes and obesity



Despite Dire Predictions, Health Care Reform Hasn’t Hurt Employer-Sponsored Coverage Rates



BCBSNC proposes nearly 26 percent ACA rate increase | The Herald-Sun



The Hospitals That Overcharge Patients by 1000 Percent



Price transparency, care data policies launched by American Medical Society

The new policies encourage physicians to give patients greater price transparency on the cost of care, taking into account insurance status.



Advancing transparency in healthcare: A call to action



US Maternal Mortality Rate Unacceptable, ACOG Says



Has Maternal Mortality Really Doubled in the U.S.? - Scientific American



Some Insured Patients Still Skipping Care Because Of High Costs



Pregnancy weight changes infant metabolic profiles : OBGYN News



This image perfectly sums up what’s wrong with American health care, according to the Internet



High level of profit by area hospitals defended by health care providers, questioned by critics as excessive, economically harmful - Eau Claire Leader-Telegram



Value-Based Healthcare Is Often Fee-For-Service With A New Coat Of Paint



Health Disparities in U.S. Still Persist According to Report - NIH



Tales of high deductibles: Delaying care over cost



Teenagers Seek Health Information Online, but Don’t Always Trust It



Bonus: Weird surrealistic representation of the role of an obstetrician (Library of Medicine)

Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports



Issue 7, June 5, 2015



The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

Tne Unnecesarean in your inbox? Yes, please! Enter your email address:


Want everyone to see your product or service here? Find out how!


A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth

This is a great excerpt from Neel Shah’s NEJM article…

“That’s why I personally never perform cesarean sections that are unnecessary: if the baby initially has low Apgar scores, I’m convinced I did the cesarean just in time; if the baby initially has great Apgar scores, I still did the cesarean just in time. Without a counterfactual, and with limited data to guide me (generally speaking, pregnant women are not excited about becoming experimental subjects), I can believe that my decision making is always accurate.

Or is it?”




Are hospitals the safest place for healthy women to have babies? An obstetrician thinks twice

“In parts of the world where women do not have access to skilled birth attendants, large numbers of mothers and babies die from preventable causes. Even for the healthiest among us, walking into the woods to have your baby would be unwise. Still, much of the developed world offers only one pragmatic alternative: the hospital. For more than a half-century, we have believed that spending many hours, if not days, in a hospital bed with a smattering of ultrasound gel, clips, wires, heart tones, random beeps and routine alarms is the safest way to have a baby.

Many of the patients I care for benefit from my surgical training. I get to save lives while also sharing in one of the most profoundly joyous moments that families experience. But obstetricians like me may be hardwired to operate, and too many operations are harmful to patients. One strategy to fix this might be to change our wiring. Another may be the British way: for patients to stay away from obstetricians altogether – at least until you need one.”




Amy Tuteur responded on the TimeIdeas blog by putting words in current Harvard OB-GYN Neel Shah’s mouth:

“The real question Dr. Shah appears to be asking is: are home births safe enough that we should save money by encouraging them?”

[While that doesn’t actually appear to be a question that Dr. Shah is asking in these articles, it is a good question in my opinion from a patient safety perspective. Cost issues aside, is home birth in particular as it stands today as an un-institution in the U.S. as safe, integrated and regulated in all states as it should be before promoting it as an alternative to giving birth in a hospital? It’s a solid stand-alone question.]





Measuring Gestational Age in Vital Statistics Data: Transitioning to the Obstetric Estimate

Beginning with the 2014 data year, the National Center for Health Statistics is transitioning to a new standard for estimating the gestational age of a newborn. The new measure, the obstetric estimate of gestation at delivery (OE), replaces the measure based on the date of the last normal menses (LMP). This transition is being made because of increasing evidence of the greater validity of the OE compared with the LMP-based measure




Swept under the carpet: The psychological side of maternal health

In high-income countries, as many as 10 to 15 percent of women experience depression, anxiety, or other non-psychotic mental health challenges during pregnancy or the year after giving birth. In developing countries, the chances rise to 16 percent of pregnant women and 20 percent of postnatal women, according to Jane Fisher, professor of women’s health at Monash University in Melbourne, Australia.





Session at Health Datapalooza 2015 on an OB care study (http://healthdatapalooza.org/detailed-agenda/)

This presentation will be two pronged. First, it will include a brief overview of our initial study at George Washington University and its results. Second will be a panel featuring Doctors Jill Krapf, Kathyrn Marko, and Andrew Meltzer, clinicians at the George Washington University, who were the principal investigators. In our study, more than 150 expectant mothers were recruited for the program and subsets of those patients were provided with the full Babyscripts experience that included connected devices. We found that Babyscripts enhances patient satisfaction with their prenatal care, improves patient compliance, and engagement and could potentially decrease healthcare costs by avoiding unnecessary visits for low-risk patients. Our goal for this session is to demonstrate the active collaboration that is required between clinicians, entrepreneurs, and technologists to leverage this new paradigm of health data in clinical care and commercialize digital healthcare solutions.

Moderator: Anish Sebastian, Babyscripts

Panelists: Jill Krapf, MD, The George Washington University; Katie Marko, MD, FACOG, The George Washington University School of Medicine and Health Sciences; Andrew Meltz, MD, 1EQ



Woman Forced Into Episiotomy Fights Back With Lawsuit

“I do civil rights work and this is a civil rights case, and it’s pretty outrageous that she would be so treated by a physician when she clearly was not consenting to an episiotomy,” Merin tells Yahoo Parenting. “The physician acted in total disregard of the patient’s interest — either because he practices backward medicine…or because it was just heartless for some other reason.”




Castlight Health Releases U.S. Healthcare Affordability Index

[Press release]

Castlight Health, Inc. … today announced the release of a new study designed to illustrate the relative affordability of U.S. regions for employers and their employees. The U.S. Healthcare Affordability Index examines the correlations between annual wage and healthcare cost changes year-over-year from 2013 to 2014 in 35 U.S. cities and metro regions. This year’s Index shows an alarming trend of rising healthcare costs across the country.




Sorry, Captain there’s no transparency in medical pricing

“In my view, high deductible plans are a pretty crude instrument to encourage cost consciousness and price transparency.”




Easy Access to Info on Costs of Medical Procedures Remains Key Provision of Bill (New Jersey)

A continuing legislative battle over whether and how limits should be placed on payments to doctors and hospitals outside of patients’ insurance networks could lead to greater transparency in the form of a state Healthcare Price Index, according to the most recent revisions of a proposed bill.

Interestingly, the price index – which sponsors insist must be part of the legislation – is opposed by both healthcare provider and insurers, albeit for different reasons.

The legislation, which aims to prevent surprise bills for emergency and involuntary treatments outside of patients’ insurance networks could undergo more changes as legislators steer it toward an end-of-June finish line




Medicare reveals big gap in Illinois hospital pricing

Patients often don’t see hospital charges, hospital officials and health care experts say. Those who are insured typically share the cost with their insurance provider. Some uninsured Illinois residents are protected by law from high charges if they qualify based on income.


“Illinois hospitals are committed to and working on improving price transparency that will provide the most meaningful and useful information for patients,” Danny Chun, vice president of corporate communication and marketing at the Naperville-based Illinois Hospital Association, said in a statement.




State of Breastfeeding Coverage: Health Plan Violations of the Affordable Care Act

This report goes in-depth into coverage of the ACA’s breastfeeding benefits and found that women face widespread barriers to getting coverage of breastfeeding support and supplies.




Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports