When Dr. Elizabeth Bostock took over the obstetrics department at Rochester General Hospital in New York in 2019, she was alarmed by its high rate of C-sections: 40 percent of healthy, first-time mothers were delivering in operating rooms.
The figure was far higher than the 24 percent recommended by the federal government. When needed, the procedure can be lifesaving, but its overuse can prolong recovery, complicate future births and sometimes risk the mother’s life.
“Most of the worst disasters I’ve seen in my career — hemorrhages, sepsis — are related to C-sections,” Dr. Bostock said. “There is inherent risk in doing abdominal surgery.”
Dr. Bostock tried to tackle the problem through a series of discrete changes. In 2021, low-risk patients began getting routed to midwives. A new checklist in 2023 required various steps to promote vaginal delivery before surgery. Perhaps most important, she said, she had uncomfortable discussions with doctors about their individual surgery rates.
In the United States during that period, cesarean rates for first-time mothers ticked up. But Rochester General’s rate declined steadily and dramatically, reaching 25 percent this year.
That drop is among the steepest at the 1,600 hospitals that regularly report cesarean rates to the Leapfrog Group, a nonprofit that publishes metrics of hospital quality, according to a New York Times analysis of its most recent data.
Many doctors see rising C-section rates as an intractable problem. Some physicians point to women giving birth at older ages, with more complications like obesity and high blood pressure, and say the extra cesareans are inevitable.
But the success of Dr. Bostock and others shows that less surgery is possible when administrators are willing to confront the problem.
“Any hospital can do this,” said Rebecca Clark, a nursing professor who studies C-sections at the University of Pennsylvania in Philadelphia.
Maternity Care ‘Not All Objective’
In 2021, Dr. Clark published a paper showing that many fixed characteristics of a hospital — whether it was a tiny, rural facility, for example, or a bustling academic medical center — had no relationship to its C-section rate. Two factors that do matter, she and others have found, are an obstetrician’s pay and the doctor’s personal beliefs about the surgery.
Physicians and hospitals usually earn more money when they perform a cesarean, though it often requires less time. The average insurance payment to a hospital for a C-section is about $17,000. For vaginal delivery, it is just over $11,000. Studies have found that when insurers make the payments equal, surgeries decline.
Attitudes toward childbirth also affect surgery rates. For nearly a decade, Dr. Emily White VanGompel of the University of Illinois Chicago has surveyed staff members of maternity wards. She has repeatedly found that hospitals whose doctors and nurses have more negative, fearful views of childbirth have higher C-section rates.
“We need to look at the fact that it is not all objective medical decisions,” said Dr. Moeun Son, an obstetrician at Weill Cornell Medicine in New York City.
Surgery can even be a matter of time management preferences. In 2020, Dr. Son and other researchers analyzed the medical records of more than 115,000 women at 25 hospitals who had tried to have a natural labor. The researchers wanted to know whether the time of day had any influence on whether an obstetrician opted for surgery.
If C-sections were medically warranted, then the procedures would happen evenly throughout the day. But the researchers found that C-sections clustered in the early evening. Doctors, it seemed, were avoiding late-night deliveries.
Some doctors contend that the country’s stubbornly high C-section rate is unlikely to change, given the underlying medical problems of mothers today.
“The amount of high-risk work we do has increased exponentially,” said Dr. Catherine Bernardini, who oversees the obstetrics department at Bryn Mawr Hospital in Pennsylvania, where the C-section rate has risen by around 11 percentage points since 2021. She attributed the change to women having babies later in life and with more health complications.
Others’ experiences suggest that some factors are within a doctor’s control.
Franciscan Health Olympia Fields in Illinois has dropped its C-section rate by one-third since 2019, hitting 20 percent this year. The hospital did so with surprisingly simple changes, said Joan Culver, director of patient care services.
In monthly meetings, Ms. Culver made doctors aware of their C-section rates compared with their peers’. She also hung “first little lamb” signs on the doors of first-time mothers’ rooms, reminding staff that such women usually needed more time.
“I went into this with some trepidation because the number had not moved in years,” Ms. Culver said. “But then we were able to drop it dramatically.”
Money, Midwives and Patience
Dr. Bostock oversees labor and delivery at five hospitals that are part of the Rochester Regional Health system. Three have substantially reduced their C-section rates since 2021, according to Leapfrog. Rochester General, a large teaching hospital that delivers about 1,800 babies a year, saw the biggest drop.
The hospital had reformed its payment system for obstetricians before Dr. Bostock took over, no longer paying doctors more for surgery than natural labor. In 2020, that policy was extended to the system’s other hospitals as well.
One obstetrician on her team, Dr. Paul Cabral, said that under the old system, money could sit in the back of his mind as the end of his shift drew near and a woman he’d spent hours caring for had not yet delivered.
“I’m going to go home and somebody else is going to receive the financial reward,” he remembered thinking. Now, he said, that doesn’t happen. “You’re ending up being a little more comfortable around not doing a C-section.”
In 2021, Dr. Bostock began automatically routing low-risk patients into midwifery care. And last year, she gave midwives their own department within the hospital system, allowing them to make their own decisions about how they practice, rather than being overseen by obstetricians.
Dr. Bostock brought in an outside group, Spinning Babies, to educate nurses on how to position laboring patients to encourage vaginal delivery. A binder of positions to try at different stages of labor — from “Flying Cowgirl” to “Dip the Hip” — now sits at the nurses’ work station.
These changes reshaped attitudes among doctors.
“It really works,” said Dr. Alex Randall, a second-year obstetrics resident. He recalled once watching a midwife do some positioning work, and the baby “popped out” 30 minutes later, he said. “It was wild.”
Rochester is not aiming for a specific cesarean rate. Dr. Fran Haydanek, the obstetric department’s medical director, said that a hard-and-fast rule could push doctors not to operate even when it was necessary. (Britain recently backed away from such targets for that reason.)
New York State’s Medicaid program recently began giving bonuses to hospitals, including Rochester, that make progress toward a goal of an 18 percent C-section rate for healthy, first-time mothers. The program said it had paid out about $40 million so far, and had seen a percentage point drop in the rate at hospitals that treat high volumes of Medicaid patients.
Rochester’s C-section rate ticked up a few percentage points this year after a steady decline from 2021 to 2024. Dr. Haydanek said she spent about six hours a month reviewing every C-section the hospital performed to look for new ways to lower rates.
Last year, during her November review, she noticed six cases in which patients had their labor medically induced. After laboring for a while, they requested C-sections. Nurses and midwives told her that patients were arriving with unrealistic expectations of how quickly childbirth would progress.
So this spring, Rochester made two new changes for women scheduled for an induction. Doctors now offer to place a balloon in the cervix two days before the procedure, to shorten their time in the hospital, and they provide a prenatal education class about induction. Kerry Snyder-Torres, a nurse who teaches the class, tells them to expect three days of labor.
Taylor Moore, 20, arrived at Rochester on an early morning in June after laboring all night at home. She rested in a dim hospital room with fairy lights strung behind the bed. Nurses flitted in and out, moving her into various positions. It was her first birth, and things plodded along.
“If this is your first, you want to save your energy,” a nurse, Liza Lambert, said when she came to check on Ms. Moore around 11 a.m. “It’s a marathon.”
Three hours later, Ms. Lambert returned, and helped flip her onto her side. Around 3 p.m., Ms. Moore’s son was born, weighing nearly 9 pounds with a full head of dark hair. The next day, holding him, she described a feeling of accomplishment.
“They gave me as much time as I needed,” she said.
Sarah Kliff is an investigative health care reporter for The Times.
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