Before Pam and Brad Taggart welcomed their firstborn Mason in late January, they had no formal labor and delivery strategy. They hadn't scheduled an induction or set a date for an intentional Caesarean section.
Doctors and hospitals are not required to release their C-section rates to the media or to their own patients.
While the S.C. Medicaid agency and the Birth Outcomes Initiative are combing hospital-specific C-section data to target facilities that need improvement, the agency is prohibited by state law from making those rates public.
Any records that identify patients or individual providers, including doctors and hospitals, are protected under the law and are not subject to disclosure requirements under the state's Freedom of Information Act.
"(C-section rates) should be public," said BZ Giese, director of the Birth Outcomes Initiative. Her boss, S.C. Medicaid Director Tony Keck, agreed.
"People have a certain expectation to understand exactly what they're paying for," Keck said. "Are they paying for a doctor that has a 60 percent C-section rate or are they paying for a doctor that has a 10 percent C-section rate?"
The Medicaid agency released county-level C-section rates to The Post and Courier for this article. This data represents only mothers who were covered by Medicaid at the time of delivery.
Medicaid pays for more than half of all births in South Carolina.
Dr. Laura Long, chief medical officer for BlueCross BlueShield of South Carolina, the largest private health insurance company in the state, said the C-section rate for its patients is only slightly higher than the C-section rate for Medicaid patients. The company would not disclose specific information.
Several Charleston-area hospitals did release information about their C-section rates for this article, but the facilities calculated those rates differently, making it difficult to compare one hospital to another.
For example, Roper St. Francis Healthcare's systemwide C-section rate was 29.3 percent in 2013, but this applies only to first-time mothers who were having one child and whose fetus was pointed in the ideal position for vaginal delivery. The overall C-section rate for the hospital system was likely higher.
A spokesman for Trident Health said its systemwide rate is 30.5 percent for all mothers. Medical University Hospital reported that 2,276 mothers delivered babies at the hospital last year, and 845 of those had C-sections, making its overall C-section rate about 37 percent.
East Cooper Medical Center disclosed that 154 first-time mothers whose fetus was positioned normally for vaginal delivery had their babies by C-section last year, but the hospital did not release its C-section rate.
"It's hard to compare apples to apples when you're looking at hospitals," said Dr. Amy Picklesimer, a maternal-fetal specialist in Greenville and clinical lead for the Birth Outcomes Initiative. "(Obstetrics) is widely competitive. We don't want to lose market share. It gets really touchy by hospitals and by provider."
"We didn't really make a plan," Pam Taggart said. "When he was ready, he was ready."
It turns out Mason decided he was ready just after the Taggarts tucked in around midnight on Jan. 26 - five days before Pam's due date.
"We had just laid down to go to bed. I was just hoping - if you could (deliver) at 8 a.m.," Brad Taggart told his wife that night on Johns Island. "As soon as I said that, 'I think my water broke.'"
Twelve sleepless hours later, Mason arrived at St. Francis Hospital in West Ashley.
"It wasn't as bad as I thought it was going to be," Pam said after her delivery. "That shocked me - in a very good way."
Brad laughed at her. "Every woman in Charleston is going to hate you," he said.
"I thought you had to wait a lot longer to get pain medication and you don't," Pam said. "Pretty much right away, you get some."
Pam delivered Mason through her birth canal, just like most women in South Carolina and across the country deliver their babies. But over the past two decades, C-sections - a common procedure by which babies are delivered through a surgical incision in their mothers' lower abdomen - have become an increasingly popular option for patients and doctors.
While most C-sections are performed because a doctor deems it medically necessary to protect the mother or child, the procedure also is perceived as a more convenient way to deliver babies, simpler than letting pregnancy run its natural, unpredictable, painful course.
"Our society is terrified of having vaginal deliveries," said Ginger Ballentine, a clinical information analyst at Roper St. Francis Healthcare. "For whatever reason, the medical community has, you know, taken this major abdominal surgery and downplayed the complications that can come from it."
While the national C-section rate plateaued at around 33 percent of all births between 2007 and 2011, that's still a sharp increase from the mid-90s, when the rate was only slightly higher than 20 percent.
Experts like Ballentine are concerned that the status quo, although relatively stable now, is still too high. They say the procedure not only costs the health care system too much money, but that C-sections are actually less safe for mothers and their infants.
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint statement last month encouraging doctors and hospitals to safely reduce the number of C-sections they perform.
"If you look at medicine in general, it's usually been very patriarchal. You know, 'You're not going to tell me how to run my practice. You're not going to tell me how to manage my patients,'" Ballentine said. "We're just starting this whole journey with our physicians. I've told them, let's do this before the state makes us do it."
That may be sooner than later.
South Carolina's C-section rate is only two percentage points higher than the national average, but data released by the state Medicaid agency shows that the rates vary widely by county and by hospital.
'Range of variation'
For example, in Abbeville, Chesterfield, Darlington, Dillon and Kershaw counties, at least 40 percent of first-time moms covered by Medicaid delivered their babies by C-section between April and June last year, even though there was no medical reason for performing the procedure on these patients.
Some of those cases may be explained because the mothers lived in rural communities, farther away from a hospital than a mom in Charleston, Greenville or Columbia might live. Scheduling a C-section offers some peace of mind.
But other rural counties in South Carolina posted very low C-section rates for the same category of Medicaid patients during the same three months.
In Hampton and Colleton counties, the C-section rates were less than 15 percent for first-time mothers covered by Medicaid with no medical indication for the procedure. In Chester County, it was less than 7 percent.
The C-section rate for Charleston County Medicaid patients who were delivering their first child and presented no medical indication for the surgery was 29 percent between April and June last year.
"I see a range of variation that is clearly too wide," said S.C. Medicaid Director Tony Keck. "Unwarranted variation is the biggest secret in health care. ... We have to start working on why are there these outliers."
Cost per patient
Keck charged the South Carolina Birth Outcomes Initiative with that task. He warned the group on Tuesday during a meeting at the South Carolina Hospital Association in Columbia that the Medicaid agency will start penalizing hospitals - maybe as soon as October - if their C-section rates are too high.
Keck said his department needs to figure out how to save $100 million next year. He sees reducing the number of C-sections that the Medicaid agency pays for as a way to help accomplish that. Medicaid pays for more than half of all births in the state.
While the agency spends more money on vaginal deliveries than C-sections each year, the cost per Medicaid patient is much higher for women who have C-sections.
A vaginal delivery cost Medicaid an average $2,845 per patient during the 2013 fiscal year, while a C-section cost an average $4,728.
"It's that intersection for the agency between outcome and cost," Keck said. "In both regards, excess C-sections are driving excess costs ... and excess poor outcomes."
Some doctors are critical of this new focus on lowering South Carolina's C-section rate. They argue that physicians are acting only in their patients' best interest, and that the Birth Outcomes Initiative might make a more meaningful impact by addressing other problems - like making sure high-risk babies are delivered at higher-level hospitals.
Even Dr. Amy Picklesimer, a maternal-fetal specialist in Greenville and the clinical lead for the Birth Outcomes Initiative, questioned the group's new campaign, officially named "Supporting Vaginal Birth."
She said there's not enough evidence to prove that C-sections are less safe than vaginal deliveries.
"We definitely don't have science to say which is better," Picklesimer said. "I just feel like most doctors are making decisions in the patient's best interest. Education can make a difference, but there may be more constructive things we could be doing."
The Birth Outcomes Initiative has already seen some success lowering the rate of elective early inductions. Last year, the state Medicaid agency and BlueCross BlueShield of South Carolina stopped reimbursing doctors and hospitals for inducing labor before 39 weeks gestation without a good medical reason.
Artificially induced labor doesn't necessarily end in a C-section, and many women who are induced go on to deliver their babies vaginally, but data shows induced labor often correlates with a higher C-section rate.
"The 39-week initiative was really clearly the best thing we could do for moms and babies," Picklesimer said. "It was very smooth, well received, not controversial. Everybody sort of knew that delivering electively before 39 weeks was not a good thing."
But lowering the state's C-section rate will be much more complex and controversial, she said.
"When it's the middle of the night ... and you're just not sure how stressed the baby is and you just don't know, it's hard to second-guess doctors in that moment," she said. "That's why this is going to be a lot harder to do."
'Focus on tort reform'
In May, Spartanburg Regional Hospital lost a $2.5 million lawsuit after an infant was injured during childbirth almost a decade ago. According to the plaintiff's attorney's website, "Our theory was that the doctor should have opted for a C-section before that window of opportunity passed."
Experts say doctors perform C-sections more often than they need to because they are afraid of being sued.
"We all believe that the C-section rate is probably tied to malpractice," said Dr. Triz Smith, a Sumter OB-GYN and the president of the South Carolina Obstetrical and Gynecological Society.
Smith said he's offended by the S.C. Birth Outcome Initiative's new campaign, which suggests the state's high C-section rate is somehow the doctors' fault.
"It's kind of like they're saying, 'Well y'all are just doing C-sections because you want to make a couple hundred more bucks and get to the golf course,'" Smith said. "If I'm wrong, that could be devastating for the patient, the baby and me. . If they want to reduce C-section rate, they need to focus on tort reform."
Ballentine, the Roper St. Francis Healthcare analyst, made clear that C-sections are an important tool for physicians and that there are medically necessary reasons for doctors to perform them.
"We want to make sure people understand that we're not saying no one can ever have it," Ballantine said. "But there are things to do up-front to make sure those that get them are appropriate."
She said the hospital system wants to encourage doctors to stop inducing women before 40 weeks if there is no compelling medical reason to start labor early. Reducing inductions before 40 weeks will likely improve the system's C-section rate by several percentage points, she said.
"This is really kind of going back to our roots," she said. "If you look at labor and delivery, this is the way we used to do things. We weren't scheduled to death. People came in when they were in labor and then we managed them. Our society has really driven us in a completely different way."
Reach Lauren Sausser at 937-5598.
Ginger Ballentine, an analyst for Roper St. Francis Healthcare, said the system needs to reduce its C-section rate because the procedure is less safe and more costly than traditional vaginal delivery. (Brad Nettles/Staff) 1/28/14×
Pam and Brad Taggart are all smiles at the birth of their son, Mason, at St. Francis Hospital on Jan. 28.×
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