In 2020, the Department of Health and Human Services released “Healthy People 2030,” a set of objectives designed to improve the nation’s health outcomes. This year, at the halfway point, Business Insider decided to check how the country was doing against its goals.
One topic stood out. When it came to reducing low-risk cesarean sections, the US was “getting worse,” a bright red banner warned.
“It’s a cesarean epidemic,” said Dr. Emiliano Chavira, a practicing obstetrician and maternal-fetal medicine specialist in Los Angeles. “There’s a minimization of what the long-term risks are, what’s happening to our public health, and how this affects mothers.”
The more we dug, the more we realized there was a gap between the procedure’s public perception as a routine, normal part of giving birth and what experts were saying. We set out to figure out why.
We also wanted to better understand the complexity involved in a procedure that can be life-saving and is also performed around double the rate the World Health Organization says is “ideal” for maternal and infant health.
We interviewed more than 30 practicing and retired obstetricians, nurse midwives, and labor and delivery nurses. We spoke with more than 25 academics who study C-section rates and maternal health outcomes.
Because hospitals don’t always publicly disclose how frequently their doctors perform C-sections, we compiled our own data. We requested information from every state and Washington, DC. By the time of publication, we had answers from 29 states and DC. We compiled findings from over 1,700 hospitals.
We learned that doctors delivering babies have to make tough calls, and that the immediate and widespread availability of cesarean surgeries is critical to safe maternal care.
At the same time, dozens of providers told Business Insider that concerns for the health and safety of women and their newborns aren’t the only influences. Doctors told us they performed C-sections because they feared lawsuits, or because there weren’t enough staff, available beds, or time to support safe vaginal deliveries.
In reviewing decades of research, Business Insider also learned that indirect financial incentives appear to drive higher C-section rates since the surgeries are more profitable, cost-effective, and perceived to be more protective in the event of a lawsuit.
These interviews and our data analysis underlined a common theme: Too many C-sections endanger the health of women and their newborns, but a higher C-section rate appears to be better for a hospital’s bottom line.
First, we set out to get C-section rate data from hospitals across the US
Early in our reporting, we learned that the rate at which doctors performed C-sections in the US skyrocketed since the late 1960s, when the surgery first became widespread. It tripled within the first decade, then doubled again by the early 2000s.
We wondered if elective C-sections were driving up the rate, and then found that only about 2.5% of babies are delivered in the US that way.
We learned that researchers in the 2000s found that pregnant women in the US are increasingly older, more likely to be obese, and are more frequently diagnosed with other complications, such as diabetes — all factors increase the chance that a baby will be most safely delivered by C-section.
That didn’t explain one of the most surprising lessons: Doctors at different hospitals perform C-sections at wildly different rates, studies repeatedly found.
Controlling for a constellation of factors — hospital obstetric care levels, delivery volume, urban or rural location, maternal age, race, health, and income — multiple studies show one of the biggest risks for undergoing a medically unnecessary C-section is the hospital a woman delivers in.
A woman looking for the C-section rate at her nearby hospital may not find it. Some hospitals voluntarily disclose their rates in response to annual consumer surveys; many do not. Business Insider set out to build a more complete picture.
State health departments collect data on all babies born in their state, including when, where, and whether they’re born vaginally or by cesarean surgery. Business Insider requested this data from all 50 states and Washington, DC.
Eleven states would not produce data that identified individual hospitals. Of those, 10 — Arizona, Arkansas, Colorado, Connecticut, Hawaii, Idaho, Missouri, Nebraska, and South Dakota — said the data was confidential by department policy or state law. The Louisiana Department of Health said the state does not track C-section rates by hospital, the only state in the country to say this.
Twenty-eight states require a formal public records or data request, sometimes for fees that reach $1,500. By the time of publication, 18 states and Washington, DC, produced data for Business Insider.
Kentucky’s first-time and low-risk C-section hospital rates produced state-wide averages that differed significantly from those reported by federal agencies, so Business Insider excluded them from our analysis.
Eleven states release C-section rates by hospital on publicly accessible websites, which Business Insider pulled directly.
In total, 29 states and Washington, DC, provided at least one of three types of C-section rates for hospitals that delivered, on average, 100 or more babies a year: overall, first-time, and low-risk.
All regions produced hospitals’ overall C-section rates, which include women undergoing their first C-sections and women who have undergone the procedure before.
Twenty-three states and Washington, DC, produced first-time C-section rates at 1,242 hospitals. We analyzed this rate because maternal health experts stress the importance of limiting first-time surgeries. Her first surgery almost always leads to others, which in turn increases her risk of developing more severe complications.
Eighteen states and Washington, DC, provided low-risk, or NTSV, C-section rates at 1,097 hospitals. Experts look at the rate doctors perform surgeries on women with low-risk, NTSV pregnancies — women who are pregnant for the first time, are at full term, are not delivering twins, and whose babies are head-down rather than breech — since they are the least likely to require surgery to most safely deliver their babies.
Relying on expert guidance, Business Insider considered low-risk C-section rates to be the most authoritative for comparing across different hospitals. Women with low-risk pregnancies may still have other complications, such as preeclampsia, which would most likely require a C-section to safely deliver their newborns. Experts overwhelmingly agree that low-risk C-section rates are still the best available metric.
For states that did not produce low-risk C-section rates by hospital, Business Insider relied on first-time C-section rates. If neither low-risk nor first-time C-section rates were available, we used the overall C-section rate.
In total, we analyzed at least one of three types of C-section rates from 1,744 hospitals that collectively delivered an average of over 2.6 million babies annually — around 70% of the babies born nationwide each year.
Nearly one in three were delivered by C-section, Business Insider’s data shows, around the same as the national C-section rate over the last two decades.
Then we calculated each hospital’s average C-section rates
Health departments provided annual C-section rate data over different time periods. Twenty-six states and Washington, DC, provided data for at least five years, all since 2018. Florida’s data is the oldest, ranging from 2015 to 2019. Public websites for California and New York each provided one year of hospital C-section rates in 2024 and 2022, respectively. Hospital C-section rates may have since changed.
Guided by input from maternal health experts, Business Insider calculated individual hospital overall, first-time, and low-risk C-section rates as an average over all years provided. This helped ensure that the rates we examined weren’t outliers.
Since we used a hospital’s average, the rates Business Insider used may still reflect higher rates for hospitals with some years of high C-section rates, even where they have worked to curb their C-section rates year-over-year.
Next, we mapped the hospitals’ locations and compared their C-section rates to others close by
We found that hospital average C-section rates swung to extremes, dipping as low as 4% overall at a hospital in Alaska and as high as 62% overall at a hospital in Florida.
To track how individual hospitals impact care, we first matched each hospital to addresses in the US Centers for Medicare and Medicaid Services’ hospital general information database. Using the latitude and longitude of each address, Business Insider then deployed a Python programming script that used geospatial data to identify each hospital’s nearest neighboring hospital in our dataset.
Next, we compared C-section rates across each hospital and its nearest neighbor. Business Insider identified hundreds of hospitals with higher rates than the next closest hospital, including 158 hospitals with an average low-risk C-section rate at least 25% higher than that of the next closest hospital.
Business Insider created a searchable map, which, for the first time, maps hospitals across 29 states and Washington, DC, and makes C-section rates publicly available to compare across nearby hospitals.
Hospitals change ownership — and names — frequently. Business Insider used the hospital name provided by each state’s department of health. Hospital names in our database may have since changed.
We determined whether a hospital was for-profit, and whether that impacted C-section rates
What’s the difference between neighboring hospitals with wildly different C-section rates? Decades of studies show a correlation between profits and higher C-section rates. Dozens of doctors, nurse-midwives, and labor and delivery nurses told us hospitals looking to maximize revenues and keep operating expenses low are indirectly incentivized to keep surgery rates high.
To investigate further, Business Insider used the US Centers for Medicare and Medicaid Services’ hospital general information data to determine if a hospital is nonprofit, for-profit, or public. Business Insider used SEC filings, court filings, and previous news coverage to further determine and confirm operational model and ownership of individual hospitals across the 29 states and Washington, DC.
Business Insider also confirmed that the hospital’s operational model had not changed at some point during the analyzed data period. If it had, we factored that change into the analysis.
We found that across nearly all 29 states and Washington, DC, for-profit hospitals, on average, performed C-sections at higher rates than other hospitals. Collectively, for-profit hospitals across Business Insider’s analysis overall had a 20% higher first-time C-section rate and a 14% higher low-risk C-section rate than other hospitals.
C-sections are more profitable and more cost-effective than vaginal deliveries, experts and repeated studies found. Our findings are consistent with many studies that found that indirect financial incentives appear to drive higher C-section rates.
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