The best fetal maternal outcomes for new moms are in some of the least expensive neighborhoods within California’s major cities, an analysis of data in a recent study by the California HealthCare Foundation shows.
The statewide trend is illustrated locally across the Bay Area and in San Francisco, where the best hospital labor and delivery metrics are often in areas where median housing prices are some of the lowest. The study looked at cesarean sections, breast-feeding, episiotomy and vaginal birth after cesarean section.
But why there is correlation between outcomes and the wealth of the surrounding neighborhood is an open question. Experts say looking at just the cost of living in an area doesn’t provide a complete explanation for varying outcomes. There are many disparate factors within childbirth metrics, including the demographics of the patient population, as well as the values of the hospital’s physicians and staff.
“It’s local culture by and large,” said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative, and chairman of the Department of Obstetrics and Gynecology of California Pacific Medical Center. “Labor and delivery is driven by physicians, nurses and patients. Everyone contributes to that. It’s [about] how people value normal birth … And that varies.”
In San Francisco, the study by the California HealthCare Foundation gave the highest score for labor and delivery outcomes measured to San Francisco General, which had a cesarean section rate of 16 percent. San Francisco General is located on the east side of the city’s Mission neighborhood, where the median home price around the hospital is about $675,000, according to Trulia’s home pricing index.
California Pacific Medical Center, which handles nearly 44 percent of the city’s births, was ranked third out of the four major hospitals in the city. Notably, one out of four new mothers there received a cesarean section, according to the San Francisco Department of Public Health. California Pacific Medical Center’s California campus is located in Pacific Heights, one of San Francisco’s most expensive neighborhoods, where the median home price is about $1.4 million. California Pacific Medical Center also offers a smaller volume labor and delivery center at its St. Luke’s Campus, located in San Francisco’s “Mission” neighborhood where the median home price is over $1.1 million.
According to the most recent regulations from the American College of Obstetricians and Gynecologists, cesarean sections are thought to be associated with less favorable outcomes, especially for future pregnancies.
Despite that, many patients and doctors still prefer to plan a caesarean section over having natural childbirth. Some women opt for cesarean section procedures to natural birth, avoiding pain and tearing, said Dr. Angie Jelin, a former maternal fetal medicine specialist at UCSF (University of California, San Francisco) Hospital. Scheduled cesarean sections also allow women to plan exact arrival dates for their babies, she added.
The ability to schedule births can also be attractive to hospitals and their physicians from an economic perspective, said Rachael Kagan, chief communications officer at San Francisco General.
“There is a notion of scheduling births, of scheduling cesarean sections … Sometimes you’ll see the [cesarean section] rate reflect scheduling priorities for physicians and the convenience for the provider team,” Kagan said.
San Francisco General is a public hospital, unlike the majority of California hospitals, including California Pacific Medical Center, which are private. Being a public hospital means physicians are salaried, “so there is no incentive for physicians to bill differently,” Kagan said.
Yet some hospitals also stand to make higher profits from cesarean section procedures versus natural births. The average total cost for a cesarean procedure is 67 percent higher than the cost of a traditional vaginal birth, according to a 2013 study by Truven Health Analytics. In the study, cost was defined as the amount that employers, Medicaid managed care plans, Medicaid programs and others pay hospitals, clinicians and other service providers.
Another factor in outcome measures may have to do with varying hospital policies with regard to patient care. Both San Francisco General and UCSF offer extensive midwifery services in addition to traditional delivery doctors. California Pacific Medical Center does offer midwifery services but to a lesser extent.
In general, midwives are trained to promote natural birth over surgical procedures. They are also heavy supporters of breast-feeding. Jelin says during the daytime hours at UCSF, almost all patients see a midwife during their care, unless they are classified as high-risk. Because midwives cannot perform cesarean sections themselves, she says, it stands to reason that procedures might be lower at hospitals that rely heavily on their services.
San Francisco General has midwives available to every patient 24 hours a day, as well as a volunteer doula program, Kagan said. “We have a commitment to providing many forms of complementary care, which [can] reduce extreme interventions.”
Main of California Pacific Medical Center cautions against evaluating hospitals based solely upon select metrics, such as cesarean section and vaginal birth after cesarean section. When evaluating hospital outcomes, consideration should be given to patient demographics, such as age, insurance type and race, he said.
“Our patients are much older than those at San Francisco General,” Main said in addressing the differences in cesarean section procedures between the two hospitals. “We have the oldest [patient] population in the state of California. Almost half our mothers are over 35.”
At San Francisco General, 54 percent of labor and delivery patients are between 20 and 29 years old, according to the San Francisco Department of Health. At California Pacific Medical Center, nearly 75 percent of patients are between 30 and 39 years old.
Main also noted higher rates of cesarean procedures in privately insured patients and differences in insurance policies between patients at respective hospitals. Nearly 85 percent of patients at California Pacific Medical Center have private insurance, while nearly 95 percent of patients at San Francisco General Hospital have insurance through government-funded Medi-Cal.
Ultimately, Jelin attributes trends in hospital performance metrics to patient preferences.
“At UCSF, we wouldn’t give elective C-sections, but other hospitals will. So if you’re a patient who wants that, you’ll go [elsewhere]. The same is true for midwives. The patients who came to UCSF tended to want that service,” Jelin said. “Patient choices do dictate outcomes to some extent.”
CLARIFICATIONS – Editor’s Note (4/15/2015): This story, originally published April 13, 2015, has been updated to clarify that California Pacific Medical Center also offers a smaller volume labor and delivery center at its St. Luke’s Campus, located in San Francisco’s “Mission” neighborhood. Additionally, this updated story also clarifies that California Pacific Medical Center does offer midwifery services but to a lesser extent.