Category Archives: Region

“Maternally Yours” Radio Interview Show Notes 7/31/12

microphone-1007154_1280On July 31, 2012, I was interviewed by Maternally Yours, a radio program on WSLR 96.5 LPFM, a Community Radio station in Sarasota, Florida.  Below are the show notes with links to more information.  I went off my notes for a bit, so be sure to listen to the podcast to get the full interview.  Also check out Maternally Yours’ blog post about the show.

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Which women at good candidates for VBAC? Which are not?

Per the American Congress of Obstetricians and Gynecologists’ aka ACOG’s latest VBAC recommendations released in 2010, VBAC is a “safe and appropriate choice for most women” with one prior low transverse cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC per ACOG.

ACOG also says,

Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC [trial of labor after cesarean].

Reviewing your personal medical history with a VBAC supportive care provider is the best way to see if you are a good candidate.  I recommend getting a copy of your medical record(s) and operative report(s) from your prior cesarean(s), get the names of VBAC supportive providers, and ask the right questions.

It’s really important to qualify your care provider to ensure that they are supportive of VBAC, before you get their opinion on whether you are a good candidate.  There is a great range of practice styles from one care provider to another.

What are some of the risks and benefits of VBAC vs. repeat cesarean?

There are real risks and benefits to both VBAC and repeat cesarean. A mom can only make an informed choice when she is aware of the risks and benefits to herself, her baby, and her future fertility, pregnancies, and health.

According to the 2010 National Institutes of Health VBAC Conference, the risk of a mom dying during a elective repeat cesarean section (ERCS) is significantly increased in comparison to a trial of labor after cesarean (TOLAC).  However, the risk is still quite low in either scenario: 13.4 maternal deaths per 100,000 ERCS vs. 3.8 maternal deaths per 100,000 TOLAC.

The NIH also found that the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCS.  The risk of uterine rupture during a TOL was 4.7 per 1,000 vs. 0.3 per 1,000 in a ERCS.

2.8% – 6.2% of uterine ruptures were associated with an infant death within 28 days of birth. However it’s important to note that “the strength of evidence on perinatal mortality [the number of babies who die during the first 28 days of life] was low to moderate” due to the wide range of rates reported by the studies included in the Guise 2010 Evidence Report.  (Guise was the basis for the NIH VBAC Conference. ) The NIH identified this topic as an area for future research.

It’s important for women to understand the long term implications of multiple repeat cesareans.  A 2006 study of 30,000 women (Silver, 2006) undergoing up to six total cesareans found,

The risks of placenta accreta, [surgical injury of the bladder, bowel, and ureters],… the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units,… significantly increased with increasing number of cesarean deliveries.

Unfortunately, many women don’t think about these future risks until they are pregnant again.  According to the CDC, 49% of pregnancies are unintentional, so women really need to consider the fact that how they birth their current baby has implications for their future pregnancies and health.

[Dr. John Sullivan Jr. of Sarasota Memorial Hospital, another guest on the show, made mention of how I lead with maternal morality.  I did so for two reasons.  One, the Guise 2010 Evidence Report, when discussing the risks and benefits of VBAC versus ERCS in it’s Structured Abstract (page v), also discussed maternal mortality first.  I think this is because it is one of the primary questions moms have: what is my risk of dying?  Second, one of the ways that unsupportive care providers coerce women into a repeat cesarean is by misleading them on the risks of VBAC including uterine rupture and mortality rates.  So, I wanted women to know from the get go what the risks were.]

If evidence shows (and ACOG supports) that most women with one or even two or more prior Cesareans should be allowed a trial of labor, why are so many hospitals and physicians still banning the practice?

This is primarily due to the 1999 and 2004 ACOG recommendation that a doctor be “immediately available” to perform a cesarean.  Yet ACOG did not clarify if they meant an obstetrician or an anesthesiologist nor did they provide a standard for where the obstetrician and/or anesthesiologist should be or what they could be doing.

As a result, hospitals developed their own definitions producing differing VBAC protocols and requirements.  The most severe variety was the institution of VBAC bans in one-third of all American hospitals per the International Cesarean Awareness Network’s 2009 survey.  These bans disproportionally affect women living in rural areas as they may have to drive hundreds of miles in order to birth at a VBAC supportive facility.  The 2010 ACOG guidelines acknowledged that the interpretation of the prior recommendations were limiting access to VBAC and clarified that was not their intention.  ACOG even says,

Importantly, however, none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option.  In settings where the staff needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture.  Drills or other simulation may be useful in preparing for these rare emergencies.

These same policies and procedures would also enable hospitals to respond rapidly to the increasing complications we see with multiple prior cesareans including placenta accreta. Read more here.

If women want to learn more about how hospitals without 24/7 anesthesia can provide VBAC safely, they can watch Dr. David Birnbach’s presentation from the 2010 NIH VBAC Conference or read his presentation abstract.

What can a mom do if she wants to birth at a VBAC ban hospital?

Dr. Stuart Fischbein, a Southern California OB, has talked extensively about his struggles as a VBAC supportive OB who worked at a VBAC ban hospital.  For a while, he told his patients that they could just show up in labor, refuse surgery, and he would attend their VBAC.  When hospital administrators got wind of this, they made him put in writing that he would not longer advise his patients of their legal right to refuse surgery.

Women have VBACed at ban hospitals. The problem is when an obstetrician is under tremendous pressure from hospital administrators to only perform repeat cesareans.  So with this pressure in mind, if a mom is told her baby is in distress, how does she know if her OB is telling the truth or succumbing to the pressure of hospital administrators?

Further resources:

Tell us about the legality of VBAC

Hospital-based VBAC is legal in all 50 states.  In some states, it is illegal for a midwife to attend a VBAC either at home or in a birth center.

What are some of the myths of VBAC?

So many persistent yet very false myths!  First, women should know that you can induce a VBAC.  Without medical indication, the increased risks are generally not worth it.  But for those women who have a medical reason, such as preeclampsia, severe fetal growth restriction, diabetes, chronic pulmonary disease, etc, an induction can be a nice alternative to a repeat cesarean.  Of course, every mom should review the risks and benefits of her options with her care provider.  ACOG says that Pitocin and Foley catheter induction is acceptable in a VBAC whereas Cytotec is contraindicated due to the high rates of uterine rupture with which it is associated.

Another myth is that your risk of uterine rupture doesn’t increase much after a cesarean or that your risk is the same or similar to an mom who has never had a cesarean.  One study from the Netherlands (Zwart, 2009) including over 350,000 births found the risk of uterine rupture in an unscarred uterus to be very, very small: about 1 in 14,000.  That same study found risk in a scarred uterus to be about 1 in 156 (this figured included induced and augmented TOLs).

Uterine rupture in a scarred uterus occurs at a rate similar to placenta abruption, post-partrum hemorrhage, and cord prolapse.  It’s not that the risk is so high in an scarred mom, it’s just that it’s so very, very, very low in an unscarred mom.

Another myth is that the risk of uterine rupture in a scarred uterus is similar to the risk in an induced, unscarred uterus.  This is also false.  The risk in an induced, unscarred uterus is still about 1 in 4,500.  It is very rare for an unscarred uterus to rupture induced or not.

Another myth is that you can compare the risk of birth to the risk of non-birth activities like dying in a car accident or choking on a pretzel.  However, you can’t accurately compare the risks of a daily activity like driving or eating because those risks are measured on a annual or lifetime basis.

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  This is because one’s annual risk measures their risk over the course of 365 days.  A lifetime risk is often based on 80 years which is over 29,000 days.  You are likely to be in active labor for one day, maybe two.

To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any time over 365 days or 29,000 days is unfair and confusing.  I think it’s more helpful for post-cesarean women to focus on the choice they have, VBAC vs. ERCS, and compare those risks to each other.  Don’t get bogged down in comparing the risks of birth to the risks of non-birth activities.

Finally, a special myth for Floridans.  One mom told me that since Florida had the most lightning strikes hit the ground in the nation, she was more likely to be struck by lighting than have a uterine rupture.  This is false.  The National Weather Service says, based on the number of reported lightning strike deaths and injuries, your risk of being struck by lightning is about 1 in 700,000.  This is a lot lower than the risk of uterine rupture in a scarred or unscarred uterus.

legal

Options for mom who will be “forced” to have a repeat cesarean

3/26/12- The ACLU has posted an article on their blog regarding this case where they released the letter they faxed to the OB group on behalf of the “forced CS” mom. This letter is an excellent resource for any person who works with pregnant women as it reviews the case law and illustrates that “a pregnant woman, like all other persons, has the right to refuse any and all medical interventions that she does not want, even if her doctor disagrees.  In a case called In Re A.C., brought by the ACLU 25 years ago on behalf of a woman forced by court order to undergo a life-threatening C-section, the judge explained: ‘[I]n virtually all cases the question of what is to be done is decided by the patient – the pregnant woman – on behalf of herself and her fetus.'”

A Little Background

On March 2, 2012, a doula contacted me because a GBS positive client was seeking a VBA2C. Her OB group was supportive until they withdrew support of her VBA2C plans at 37 weeks due to factors that had nothing to do with her. I suspect that the OB group – who was known to be VBAC & VBA2C supportive – had a lawsuit/ uterine rupture/ bad outcome that made them so abruptly change their VBAC policy. Nothing developed during the mom’s pregnancy that suddenly made her a poor candidate for VBA2C.

With the mom’s permission, her doula contacted me to help them determine their options. (Below you will find the initial email I received from the doula.) I’m not an attorney or a medical professional, so I could not advise them. I turned to Facebook to collect options and opinions. Through those posts, I was directed to people who could help them – OBs, midwives, reporters, legal organizations, and attorneys. Now it was up to the mom whether she wanted to contact those people/orgs to get their opinions and advice.

Her name and her doula’s name were not made public so that the mom could make this decision without the public eye directly on her and all that comes with that.

What follows below is a brief timeline of the events and then there are emails that follow sharing more detail.

The National Advocates for Pregnant Women becomes involved

Update 3/3/12 12:08 PST- I contacted the National Advocates for Pregnant Women last night and the Executive Director Lynn Paltrow replied early this morning with lawyer referrals and a review of the case law. I have included her email below with her permission. This is good information for anyone who works with pregnant women.

1:01 PST- Mie Lewis of the ACLU Women’s Rights Project recently expressed interest in taking on cases like these. Mie Lewis is in New York city and would be an excellent resource for any other women who experience similar situations.

For women in South Carolina, you can contact your state chapter of the ACLU:

Susan K. Dunn
Legal Director
ACLU, South Carolina
P.O. Box 20998
Charleston, SC 29413-0998
843-720-1425

Elizabeth Cohen, Senior Medical Correspondent for CNN and CNN’s Sabriya Rice are two reporters who have written about birth and might be worth contacting if you find yourself in a similar situation. Check out “Mom defies doctor, has baby her way” dated December 16, 2010 to get a feel for their writing.

3/5/12 6:40 PST – I learned last night that the mom was able to get her cesarean rescheduled two days later for March 7th.

ACLU, NAPW, & NBPC fax a letter to the OB group, mom has preoperative appointment

3/6/12 4:15 PST – The mom’s doula contacted me with an update. Today the mom and the doula attended the mom’s preoperative appointment for her scheduled cesarean on March 7, 2012. Early this morning, a letter composed by members of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women was faxed to the OB group. (You can read the letter here.) The mom and doula also brought a copy of the letter to the appointment. From the doula’s statement: “[The OB] said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!!”

When the OB referenced ACOG’s VBAC recommendations and the fact that they do not support VBA2C, the mom asked for the date of the recommendations the OB was using. Turns out he was not aware, and was shocked to learn, that ACOG released a new VBAC Practice Bulletin in 2010 stating, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.

This is why it is crucial for women to be informed and resourceful! What if this mom was like most moms who choose whatever mode of delivery their OB recommends without understanding the risk and benefits of their options? She would have had a cesarean at 40 weeks per an outdated ACOG VBAC Practice Bulletin.

Instead, the cesarean date has been moved back to 41 weeks (March 17th) and if mom doesn’t go into labor before that, she is OK with having a cesarean on that date. You can read the full letter from the doula detailing the pre-operative appointment below.

Mom goes into labor

3/7/12 – I’m informed that the mom’s water broke and am in communication with the doula throughout the day. Several hours after spontaneous rupture of membranes, contractions start and labor progressed, but then fizzled out. “Dr S. decided that because she had come this far only to hit a wall that wasn’t moving after trying all natural approaches, he would start a very, very, very low dose of Pitocin [starting at 2 milliunits/hour with a maximum of 4 milliunits/hour] through her IV.” Things start picking up again, but then some fetal distress was detected and Pit was backed off and finally turned off completely. Fetal heart tones stabilized but at a lower baseline than before.

Suddenly fetal heart tones drop and then disappear. A STAT cesarean is called, mom was put under general anesthesia, and within TEN MINUTES, the baby is born. Mom was fine as well.

A placental abruption was diagnosed during surgery. An abruption is when the placenta detaches from the uterine wall before the baby is born. This deprives the baby of oxygen and mom is at risk for hemorrhage. Full abruption is very dire for baby. While there is about a 6% chance of infant death or oxygen deprivation after an uterine rupture (Landon, 2004), there is a 12% risk of infant death after a placental abruption (Ananth, 1999). That is a grim statistic.

I am extremely thankful that this mom birthed where she felt safest which was in the hospital despite the many who suggested she plan a last minute home birth.  While I am supportive of home birth and I myself had a home birth, that doesn’t mean that I think all complications can be easily managed at home.  There are complications that are better served in the hospital environment.  Had she planned a home birth, she could have been totally fine, transferred in time, or she could have had a bad outcome.  The fact is, we don’t know.   I do think women who have placental abruptions have better odds in the hospital.

As the doula said of the mom,

She is very thankful she didn’t take the suggestions of some – to call in an underground midwife, to have a home birth, to go to another state and deliver, to labor at home until she was feeling pushy. Any of those suggestions could have had deadly consequences for Emily and her baby. She is thankful that she was given the opportunity to attempt a vaginal delivery, and she is thankful that her body tried to labor. Ultimately though, she is so very thankful that there was an amazing medical team who jumped right into action and essentially saved the lives of both her and her sweet baby girl. She let me know that if she could go back in time, there is nothing she would have changed.

In the mom’s own words:

I don’t think I would have done anything different. I might have said hey lets keep it [the pitocin] at two [milliunits] but hey it [the abruption] would have happened either way. It was God’s way of saying, hey this baby needs out and isn’t coming out the normal way. I let you try it now it is time for you to go ahead and meet her.

Mom is up and around the day after surgery and not needing pain medication! Hopefully this means she will have one of those easy cesarean recoveries of which I am forever jealous! Baby is breastfeeding well. I wish this mom and baby a quick recovery and a happy, happy babymoon!

You can read the doula’s full account of the birth here.

Follow Up

I’ve received a few comments questioning the use of Pitocin in a VBAC and even some comments suggesting that if the mom was at home, the abruption wouldn’t have happened because she wouldn’t have had the Pitocin.

In terms of Pitocin in VBAC moms: 99% of VBAC induced/augmented labors do NOT rupture (Landon, 2004). I haven’t seen rupture rates in VBA2C induced/augmented labors. With induction or augmentation, the increased risk of rupture comes from the drug and the dose. I do not know if the dose given to the mom is in the “danger zone.” I’d appreciate any studies that have measured Pitocin augmented uterine rupture rates and abruption rates by dose in VBAC labors.

But please know, that most ruptures occur in spontaneous labors. Zwart (2009) is a Netherlands based study that included 358,874 total deliveries, making it “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” It also differentiated between uterine rupture and dehiscence. Zwart (2009) “found of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures. 28 (13.5%) ruptures occurred during cervical prostaglandin induction. 22 (10.6%) ruptures occurred during oxytocin (Pitocin) induction.” 40% of scarred ruptures occurred during prostaglandin induction. Read more here.

In terms of Pit causing the abruption, none of us know whether that is true to not.  Certainly most women who have Pitocin do not abrupt.  Further, people said that if she was at home, she wouldn’t have been augmented, and she wouldn’t have abrupted.  None of us know that.  Some people believe the myth that nothing can go wrong in a spontaneous “unmessed with” birth.  That is a dangerous and false belief.  All complications are not the result of “interventions gone wrong.”  Sometimes you can do everything “right” and still have a complication/ bad outcome.  Here is one mom’s story of her placental abruption at home (trigger warning).  She survived, her baby girl Aquila did not.  I share this story solely to illustrate the severity of placental abruption and how having a competent care provider and immediate access to operating rooms, surgeons, and blood products can literally make the difference between life and death.  Abruption can be a very serious complication.  Most women who have home births will not have a placental abruption or any other complication that requires immediate access to surgery, but those who do will greatly benefit from a qualified care provide who can facilitate immediate transfer to a hospital.

A quick google search found this study which found a slight increase of abruption risk per mode of delivery: 1.06% during the third cesarean vs 0.91% during the third vaginal delivery. I’d be interested in reading other studies people have handy. It did not control for induction or augmentation, so if you have a study that does control by drug and dose, please share.

The OB suggested the Pit and the mom consented.  I do think that is the point.  I do think women should be given the option of augmentation/induction rather than just “required” to have another cesarean as many OBs do. As Dr. Stuart Fischbein, a breech & VBAC supportive Southern California OB, recently shared on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of misoprostol [Cytotec]) so a foley balloon or pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

I actually was impressed that the OB gave the mom the option of a gentle augmentation. It’s certainly better than just saying, “Your time in up.” I don’t know if I would have made a different choice being in this mom’s position: VBA2C, GBS+, contractions sputtering out… It’s really hard for me to say what I would have done. Yet it has seemed very easy for people  sitting at their computer the morning after to make judgements as they do not have to deal with the real risks or consequences. Sometimes you can do everything “right” and still have a bad outcome. Fortunately, the abruption was detected, surgery was performed, and everyone survived.

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3/2/12 – [This is what I wrote upon receiving the doula’s initial email.] I just received this email tonight and need ideas quick. This term mom seeking VBA2C is in the the Columbia area of South Carolina. Her OB was supportive until 37 weeks. Her cesarean is scheduled for March 7, 2012. She was told that if she shows up in labor, she will be “forced” to have a cesarean. Does anyone know of a care provider in her area that would be willing to accept a new client this late in pregnancy? What other options does she have? Additionally, I’m looking for information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do??

Jen,

I need some quick help with a client of mine and was wondering if you’d lend an ear and offer up any words of wisdom as I know you are an amazing resource to VBAC.

I have a client who is due today. She had a primary c/s 4 years ago exactly on her EDD for a breech baby. She had a RCS 15 months ago because she was carrying twins.

She is seeing the same practice who did her first two c/s, so they are well versed in her medical history. She had double layer sutures both times, good space between deliveries, deliveries were due to breech & twins and not FTP, CPD, ect… She was deemed a good candidate for VBA2C and has been planning once since.

At her 37wk check-up, the OB told her that the staff had changed their minds and could no longer offer her a VBAC. She questioned the reasoning and he said it was just too risky. She was completely blindsided by this and broke down crying – the OB left the room.

Back to her 38wk appointment and she found out the OB had scheduled her RCS for 2 days after her EDD. She confronted the OB (this time a different one than she saw the week prior) and the OB said she didn’t see any reason why she couldn’t be offered a TOLAC. Relieved, my client went on about her business. Pregnancy has been great. Minimal weight gain, no GD, BP always great. She is GBS +. She received a phone call two days later and the OB said each OB on staff had met and it was decided that a VBA2C was too risky and she wouldn’t be allowed to have a TOLAC. My client was furious, and rightly so. She tried to get in touch with the OB but played phone tag back and forth.

Her 39wk appointment came – this time with a different OB yet again. He was a total jerk. Laughed when she told him she wanted a chance to labor. She showed him the current ACOG guidelines which support VBA2C with the right circumstances (which she has) and he disregarded it and showed her a paper on the risk of VBAC. She argued yet again and said she wouldn’t consent to a c/s unless she or the baby were in danger. He told her that if she showed up to L&D in labor they would “force” her to have a c/s. Yes, he actually told her they’d “force” her. She left a crying, hurt, furious mess.

The next day she called to request her records and the OB told her again – if she delivered with their practice, it would be VIA c/s – end of story. If she didn’t want to comply, they’d (legally) find another practice to take her (HIGHLY unlikely considering she’s due today)…

She hasn’t been back since but has a section scheduled for the 5th that she intends to cancel. I am virtually her only support. Her MIL has 2 c/s, her mother had 3 c/s and thinks she’ll die if she attempts a vaginal birth. Her husband says he has to know when the baby is coming so he can plan to get off of work – so he is fine with the section and not supportive or helpful much.

We have had massively long talks over the past few days and what it boils down to is that she has two choices essentially.

#1 – Show up in labor at her current hospital and have to fight like hell to be able to labor. Almost certainly have the OB on call make the process very difficult. She voiced a concern that the OB may be so pissed off that she’s refusing a c.s that they’ll find some reason to section – “fetal distress”, baby too big, baby not fitting, failure to progress, ect… She also worries exactly what they truly mean by they’ll “force” her to have a c/s. She worries they’ll do something extreme like call DSS/CPS. She’s heard a horror story of a court-ordered c/s. I told her that all that worry, stress, and anxiety during labor will do absolutely nothing good for her well being and progress.

#2. Show up at a different hospital and deliver with the hospital OB. Problem here is she has no record of prenatal care, no surgical records to show suture status, time between sections, ect… She requested her records from the current OBs office, but no one is getting back to her (and I doubt they will…). I know they’ll look down on that and potentially try to coerce into a section due to that. She feels she’d face the least opposition going this route, but has concerns.

I’m exhausted and so is this mama. She is still firm in her choice that a VBAC is the best and safest option for her and her child and I fully support that. I’m not even sure what the right option is at this point or where to turn or what to do. I’m trying to let the mama guide but she’s looking to me as if I can somehow make this entire situation go away… I wish I had the answers, but I don’t.

I was just wondering if you had any information on the legality of a hospital/OB “forcing” a c/s? What happens if she shows up at the current hospital and refuses to sign the c/s consent form? What exactly CAN they do?? Have you had any experience in with cases like this?? What option do you feel would be best (#1 or #2) and how should I direct the mama to handle the staff? What is my role here? I’m just at a loss and felt I needed to seek counsel…

Thank you for listening, I know it was so long..

3/3/12 – I receive an email from Lynn Paltrow, Executive Director for the National Advocates of Pregnant Women:

Dear Jen:

By this email,I am cc’ing two lawyers in South Carolina, Susan Dunn and C. Rauch “Rock” Wise, and SC activist Sally Hebert as well as other people out of state who may have useful suggestions, including Farah on our staff who is especially knowledgeable about cases involving threats of forced cesarean surgery. I know a great deal about the law in South Carolina but am not admitted to practice there, so any legal questions should be directed to lawyers admitted to the bar in South Carolina.

I can, however, share with you some general background. As a matter of constitutional law, medical ethics, and human rights, doctors may not force their patients — including pregnant ones — to undergo procedures they do not consent to.

As a policy matter, both the American Medical Association and the Ethics Committee of the American College of Obstetricians and Gynecologists have taken express positions opposing court ordered interventions against pregnant women and against effort by hospitals and doctors to seek such orders. The American College of Obstetricians and Gynecologists has issued a formal opinion stating that “actions of coercion to obtain consent or force a course of action limit maternal freedom of choice, threaten the doctor/patient relationships, and violate the principles underlying the informed consent process.” See American College of Obstetricians and Gynecologists Committee Opinion No. 55, Patient Choice: Ma­ternal-Fetal Conflict (1987) (And more recent opinions 2005); Report of American Medical Association Board of Trustees, Legal Interventions During Pregnancy, 264 JAMA 2663, 267 (1990) (“Judicial intervention is inappropriate when a woman has made an informed refusal of a medical treatment designed to benefit her fetus.”)

Appellate cases decided on full records and addressing the issue of court ordered interventions on pregnant women have held that the medical and constitutional principles of informed consent, bodily integrity, and patient privacy and autonomy require that pregnant women have the right under the common law and the constitution to accept or refuse medical treatment, like all other patients. See In re A.C., 573 A.2d 1235, 1253 (D.C. 1990) (en banc) (vacating a court-ordered cesarean section that was listed as a contributing factor to the mother’s death on her death certificate); In re Fetus Brown, 689 N.E.2d 397, 400 (Ill. App. Ct. 1997) (overturning a court-ordered blood transfusion of a pregnant woman); In re Baby Boy Doe, 632 N.E.2d 326 (Ill. App. Ct. 1994) (holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a cesarean section must be honored even if the choice may be harmful to the fetus). Cf. Stallman v. Youngquist, 531 N.E.2d 355, 359-61 (Ill. 1988) (refusing to recognize the tort of maternal prenatal negligence, holding that granting fetuses legal rights in this manner “would involve an unprecedented intrusion into the privacy and autonomy of the [state’s female] citizens”).

Nevertheless, South Carolina stands out in the nation for having judicially created law that treats viable fetuses as if they are separate persons. As a result, certain women have been found guilty of child abuse for risking harm to their unborn children. None of these cases in South Carolina, so far, involve women who have refused cesarean surgery. These decisions, do apparently embolden doctors to believe they can impose their view of what is best on their patients.

Theoretically, it might be possible to go to court to get a Temporary Restraining Order –ordering the hospital not to do as they have threatened. If Susan or Rauch or another South Carolina attorney and the client wish to and are able to go this route, our office may have some draft/model papers that would help with such an effort and we would be happy to consult with/advise/share information with that lawyer.

Regardless, however, of what rights this woman has on paper, she has to deal with the stress of this situation and ensuring that she has access to the health care she does need and want. I cannot advise on what medical course she should take.

I can say though that, however she proceeds NAPW would be very interested in also exploring how we could help if she wishes to challenge these actions after the birth or bring them to public attention. Similarly, if child welfare is called,(something else that would not be supported by constitutional law etc– but is a scary, if remote, possibility) NAPW would be interested in helping her local counsel.

I will be on a plane this morning, but my cell phone is below in the signature block. When it gets a bit later, I will try and reach some of the South Carolina folks by phone to give them the heads up about your email.

Please, in any event, let us know what happens. We will be worrying about this Mom.

Sincerely,

Lynn M. Paltrow
Executive Director
National Advocates for Pregnant Women
15 West 36th Street, Suite 901
New York, New York 10018
212-255-9252
212-255-9253 (fax)
917-921-7421 (cell)
lmp@advocatesforpregnantwomen.org
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3/6/12 4:15 PST – Update from mom’s doula:

Thank you everyone – especially Jen – for uplifting this mother in your thoughts and prayers and helping us join together as a community to help this wonderful mother out!

Last night, four wonderful women got together and composed a letter to the mama’s OB/GYN practice. These women were members of ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant women. Thank you so much Jen for contacting these women on the behalf of my client and myself. The letter was absolutely wonderful and explained in detail the things the practice were doing were wrong among many other things – it was very detailed!!! The letter was faxed to the practice first things this morning and a copy was sent to myself and my client.

When we arrived at the consultation, the practice had already received and read the letter and it was in my client’s chart. We were ushered directly to the OB’s office instead of an exam room. We sat down and began to discuss the issues at hand. I was providing moral support while my client took the lead. The OB explained that he believed this was all simply miscommunication. He said that while they have very strong feelings on things such as this, they could not and would not force her to do anything and that no one would come and drag her out of bed tomorrow for her scheduled cesarean. He said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That right there tells me that the point and purpose of the letter had worked!! I knew when I read the letter that it was either going to upset the practice tremendously and they would seek a court order for a cesarean, call DSS/CPS for her endangering her child’s life since SC is a personhood state, or something similar. Alternatively, the letter may shake them into reality and make them realize they are dealing with a mother who is fully informed of her rights and ready to take action and they would back down. Thankfully, the second option ended up happening!! You could tell it was obvious he was shocked that someone went to such lengths to get their attention and fight for what they wanted.

He had the ACOG guidelines book on his desk bookmarked to the VBAC policy and showed us that VBAC after two or more cesareans is contraindicated and the ACOG doesn’t support it. He explained the risk of rupture was 1-2.6% after 2 cesarean section. He explained the risk and that if my client were his wife, he would advise she have a RCS. He was very calm and we remained very calm as well. He said that now the ball was in her court. When he was done explaining his position, my client began to explain hers. Her first question was the publication date for the VBAC ACOG guidelines he had looked up because she believed they were out of date. He looked surprised to be challenged and we took out my binder that had the most recent, revamped ACOG recommendation that is to allow a TOLAC in mothers with two prior low transverse uterine incisions. He was shocked and had no idea that the guidelines had changed…. No wonder our system is so in need of VBAC support – the doctors don’t even know their own governing body’s recommendation!! She explained that she understood the risk involved, but she also understood the risk of a 3rd cesarean section and all she wanted was their blessing to have a trial of labor. She explained that she wouldn’t hesitate to agree to a cesarean section should there arise a true need. They talked further and agreed that she would be allowed to be left alone until 41 weeks – March 17th (they have her EDD as March 11th) to go into labor and be allowed a TOLAC. No induction methods would be used. If no labor and no changing cervix by March 17th, a cesarean will be scheduled and the mom is ok with this.

Everything looks great at her appointment – she’s had no cervical change and the baby is very high still – baby is floating according to the doctor. She’s going to work to bring her baby down and prepare her body for labor. She feels as if a weight has been lifted from her shoulders and she can finally relax. We both agree that being stress-free will do a world of good and we pray she goes into labor on her own before the 17th. Send her good thoughts and prayers that her body kicks into gear and decides it is time to have a baby!!

I am elated that this took such a wonderful turn!! It was such a dark time for quite awhile! Thank you everyone for the continued support and I will keep everyone updated with the mother’s permission!! Hopefully she has a wonderful story to tell very soon!

Contra Costa Regional Medical Center Supports VBAC & Wins Award

Below I’ve included an article from MartinezPatch and I highlighted some sections.  This hospital boasts a 90% VBAC success rate.  That is huge!

As I shared in A father asks “Why invite the risk of VBAC?:

I had the opportunity to attend the March 2010 National Institutes of Health VBAC Conference where the ability of rural hospitals to safely attend VBACs was extensively discussed. One doctor spoke during the public comment period and stated that her rural hospital had a VBAC rate of over 30%! It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely. (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.) Read more about the policies that this hospital implemented: VBAC Ban Rationale is Irrational.

It just goes to show that if a hospital is willing to make the effort, they can offer VBAC safely and with “no long-term complications among patients who attempt a VBAC birth or to their babies.”  Kudos Contra Costa!

Contra Costa Regional Medical Center Wins Award for Perinatal Program

County hospital receives top honors for its program to reduce repeat cesarean sections.

December 20, 2011

Contra Costa Regional Medical Center (CCRMC) in Martinez has been honored for its perinatal program that helps more women who have had a cesarean delivery avoid the surgery with their next pregnancy.

CCRMC received the award earlier this month from the California Association of Public Hospitals and Health Systems and its quality improvement affiliate, the California Health Care Safety Net Institute. The award is given to a public hospital program that best represents an innovative approach to improving health care.

Historically, most medical providers advised women who have had a C-section not to attempt a non-surgical delivery because of the slight risk of a tear in the uterine wall during labor that can be dangerous to the mother and baby. However, in recent years established medical science has recognized that a vaginal birth after a cesarean (VBAC) is possible and preferable whenever it can be achieved safely, according to Judith Bliss, MD, chair of CCRMC’s Obstetrics and Gynecology Department.

“A non-surgical delivery carries less risk to mom and baby and allows them to bond more quickly.  The key is being able to offer this option to women who’ve had a cesarean while ensuring the safest outcome possible,” Dr. Bliss said. “It’s a great joy to be able to offer many women this choice when they thought the option didn’t exist.”

The 166-bed county hospital is part of Contra Costa Health Services and about 15 percent of all babies born in Contra Costa County are delivered there. CCRMC’s perinatal unit was able to provide previous C-section patients with the VBAC option by developing a specific set of interventions, known as a “bundle,” to ensure staff could respond quickly to any complications that might occur during labor or delivery. The interventions include the ability to perform an emergency C-section, which should be started immediately in the unlikely event that a uterine rupture should occur.

Since initiating the program in October 2009, CCRMC has had significant success in reducing the percentage of repeat C-sections among eligible patients. This year, the average vaginal delivery rate for VBAC patients at CCRMC has averaged close to 90 percent through September; the national success rate for VBAC births ranges from 60 – 80 percent.   CCRMC’s success rate has been attained with no long-term complications among patients who attempt a VBAC birth or to their babies, noted Dr. Bliss, who heads the team for the VBAC project.

CCRMC developed the VBAC program in close collaboration with the Institute for Healthcare Improvement, a not-for-profit organization based in Cambridge, Massachusetts that works with health care providers and leaders throughout the world to achieve safe and effective health care.  “At a time when many providers have shied away from offering women the VBAC option because of the challenges involved, it’s very gratifying to see this hospital make such a strong commitment to doing what it takes to give patients this opportunity,” said Peter Cherouny, MD, chair of the Perinatal Improvement Community with IHI. “They’re clearly putting their patients first and doing what’s best for both mother and child.”

“We know that there are times that we have no choice but to perform a C-section,” Dr. Bliss said. “But today women have the option of having a non-surgical delivery knowing every step has been taken to assure their safety and their baby’s. To see mom and newborn together right after the birth – skin-to-skin, breastfeeding, with their families nearby – lets us know that our efforts and our vigilance are paying off.

Go here to see a video about CCRMC’s award-winning “Vaginal Birth after Cesarean (VBAC) Improvement Project.”

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VBAC Ban Rationale is Irrational

Virginia of Hagerstown, Maryland left me this comment in response to the article Why if your hospital “allows” VBAC isn’t enough:

my hospital says that they will do a vbac but they aren’t set up for it because the labor side is far away from the c-section side so if i try to do a vbac and end up having a c section it will take a lot longer to get me to surgery. do you think this is a legitimate reason to consider not having a vbac? im too close to my due date (7 days left) to change hospitals or doctors although i am beginning to wish i would have. ..
-NERVOUS in hagerstown maryland

Hi Virginia,

The short answer is: No, that is not a legitimate reason to deny you a VBAC.

The reality is, you are less likely to experience an uterine rupture than a complication that has absolutely nothing to do with your prior uterine surgery.  (Please read Scare tactics vs. informed consent and scroll down to the chart entitled “Risks far outweigh VBAC” to see for yourself.)

Since obstetrical complications arise during labor in women with no history of uterine surgery that require immediate surgical delivery, or more commonly in women with multiple prior repeat cesareans, how can a hospital claim that they are fit to attend those births, but not yours?

Any birth (VBAC or not) could end in a medically necessary cesarean and any hospital (urban or rural) set up for birth should have a plan detailing how they will respond to those inevitabilities.

I have also often wondered how often women with true obstetrical complications requiring immediate cesareans or even car accident victims requiring surgery, have been unable to receive that care due to otherwise healthy moms and healthy babies undergoing  scheduled elective repeat cesareans occupying the operating rooms?  With 92% of American women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals.

The ability of rural hospitals to safely attend VBACs, as well as a specific plan that they could implement, was extensively discussed at the March 2010 National Institutes of Health VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital  – without 24/7 anesthesia – had a VBAC rate of over 30%!  It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely.  (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.)

As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.  The American Association of Justice article entitled “When every minute counts,” also discusses improving response times.

These drills would also be helpful to the women who have other obstetrical emergencies including placenta previa, placenta accreta, and other complications that are more common in women with multiple prior cesareans.

Additionally, as I argued here:

Scheduled cesarean section puts anyone else who experiences a medical emergency requiring surgery in danger because those operating rooms become unavailable. I wonder how often women with true obstetrical complications requiring immediate cesareans, such as your wife, or non-obstetrical emergencies such as car accident or gunshot victims, have been unable to receive that urgent, time sensitive care due to otherwise healthy moms and healthy babies undergoing scheduled elective repeat cesareans and tying up the operating rooms? With 92% of women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals, many of which only have one or two operating rooms.  These routine repeat cesareans impact everyone and it’s only going to get worse.

I highly recommend you read the Final Statement produced by the conference as it was the catalyst for the subsequent revision of ACOG’s (2010) VBAC guidelines in the Practice Bulletin No. 115 where they affirmed:

Women and their physicians may still make a plan for a TOLAC in situations where there may not be “immediately available” staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.

This is a huge change.

The term “immediately available,” first introduced in the 1999 Practice Bulletin No. 5 and then reiterated in the 2004 Practice Bulletin No. 45, was the reason why many hospitals ultimately banned VBAC.  Hopefully the removal of that recommendation in this new Practice Bulletin will result in the reversal of VBAC bans and an overall greater support for VBA1C and VBA2C.  ACOG acknowledged that their prior recommendation was resulting in way to many cesareans and the increasing risks that multiple cesareans bring are significant and unacceptable.  (Please read the risks of multiple cesareans detailed by Silver 2006 in Another VBAC Consult Misinforms.)

The removal of the “immediately available” recommendation is supported by the NIH (2010) Final Statement which found it, if implemented in all hospitals, to be an impossible standard that could result in the closing of many Labor & Delivery units:

Would provision of an anesthesiologist standing by waiting for an emergency at every hospital that practices obstetric care increase patient safety?  In truth, that person would need to be doing nothing else clinically, so even being in the hospital might not qualify for “immediately available.”  Looking at the numbers of anesthesia staff currently available, the minimum requirement to provide immediate anesthesia [per the recommendation of the American Congress of Obstetricians and Gynecologist] care for all deliveries would be to have all deliveries accomplished at facilities with greater than 1,500 deliveries annually.  This would require that approximately three-quarters of all obstetric programs nationwide be closed (Birnbach, 2010).

I am excited and hopeful to see the ripple effects of this new Practice Bulletin especially for women in rural areas.  Hopefully the option of VBAC will become a reality for more women.

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American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Kamel, J. (2010, July 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/

Birnbach, D. J. (2010). Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: Role of anesthesia availability, productivity, guidelines, and patient saftey. Vaginal birth after cesarean: New Insights. Programs and Abstracts (pp. 85-87). Bethesda: National Institutes of Health.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final Data for 2004. National Vital Statistics Reports , 55 (1), 1-102.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

National Institutes of Health. (2010, March 8-10). NIH VBAC Conference: Program & Abstracts. Retrieved from NIH Consensus Development Program: http://consensus.nih.gov/2010/vbacabstracts.htm

Another VBAC consult misinforms

At the NIH VBAC Conference, I was happy to hear the draft Consensus Statement acknowledge that there were non-medical factors that affect women’s access to VBAC:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor after cesarean]. . . We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers.

Many women assume that their local hospital has banned VBAC, or their OB doesn’t attend them, because VBAC is excessively dangerous.  Most women are unaware of the many non-medical factors that play into VBAC accessibility.

What disappointed me, however, was the panel’s surprise at the misinformation and bait & switch tactics to which many women are subjected.  I think when you are a VBAC supportive practitioner, it may be hard to believe that your colleagues practice in a manner like I describe below.

To give you an idea of the kind of advice that many, many moms seeking VBAC receive, here are excerpts of an email from Brooke Addley of northeastern Pennsylvania.  She decided to ask her OB about VBAC at her annual exam in March 2010.  This is what happened:

Once I brought the subject up stating that I really would not be open to a c-section unless it was medically necessary he said “they are all medically necessary” and then went on to mention that just within this last month there were two major ruptures at the local hospital.  From there he just talked about the risk of VBAC and how catastrophic it could be if there was a rupture.

A uterine rupture can be catastrophic, but it is rare and the incidence of uterine rupture is comparable to other obstetrical emergencies such as placental abruption which has a worldwide rate of 1%.  As Mona Lydon-Rochelle PhD, MPH, MS, CNM said at the NIH VBAC conference, “There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” and George Macones MD who stated in terms of VBAC, “Your risk is really, really quite low.”  Additionally, the risk of infant death during a VBAC attempt is “similar to the risk” of infant death during the labor of a first time mom (Smith, 2002).

One of the factors discussed at the NIH VBAC conference is that a practitioner is less likely to offer VBAC if they have experienced a uterine rupture, particularly if there is a bad outcome.  However, that ethically should not interfere with him providing his client with accurate information on the rate of uterine rupture as well as studies that substantiate the rate provided.

When I cited the low rate of uterine rupture [of 0.5% – 2% after one prior low transverse cesarean] he said “that information is incorrect and the rate is actually higher.”  Yet when I asked him to lead me in the direction of the study or studies where he found that out he said there isn’t any because many women have repeat [cesareans] and once in the OR it is discovered that they have a thin window in their uterus and if they labored/pushed it would have ruptured for sure.

The rate of rupture in a spontaneous labor after one prior low transverse incision is 0.4% (Landon, 2004). So not only did he give her an inaccurate picture about the rate of rupture, but he led her to believe that there are no studies on VBAC.  (I always wonder in situations like these: Is the OB really actively trying to mislead the patient or is he really so misinformed?)  This OB should read the NIH VBAC conference Program & Abstracts, or my VBAC Class bibliography, to see that in fact there are many studies on VBAC.

Then the OB gives her inaccurate information on VBAC success rates:

I asked the VBAC success rate and he said that most fail.

VBACs have a success rate of about 75% which has been the conclusion of many studies  (Coassolo, 2005; Huang, 2002; Landon, 2005; Landon, 2006; Macones, 2005).  Success rates vary based on a variety of factors, but to say that ‘most fail’ is absolutely false.  What this OB should say is, “Most women who attempt a VBAC with me as their care provider fail,” which is probably 100% true.

And then the OB gives her the line that many women fall for:

He did however say that although he really does not recommend it . . . he would allow me to try.

And there is the hook.  So many women are satisfied to simply be given the opportunity to VBAC.  Unfortunately, from what this OB has said already, I do not believe Brooke would have a genuine opportunity to VBAC.  Surely this OB would come up with some “valid medical reason” that she needs a cesarean sometime during her pregnancy or labor.  Here come the requirements to be granted a trail of labor:

…yet there are many things that would have to be taken into consideration, including my unproven pelvis. He mentioned that in the hospital I would have to have continuous monitoring and 18 hours after my water broke, if I was not progressing, they would want to use Pitocin to advance the labor.  He also mentioned that he does not allow any woman under his care to go past 40 weeks.

The unproven pelvis standard is bizarre.  Don’t all women pregnant with their first child have an unproven pelvis?  Do we offer them all of them an elective primary cesarean to prevent a “failed vaginal delivery?”

No stereotypical VBAC consult full of misinformation is complete without a healthy helping of repeat cesarean risk minimization:

He did not mention risks to repeat c-sections.  When I brought it up he said there aren’t any except the obvious risks that come with any surgery.

False, false, false.  According to Silver (2006), a four year study of up to six repeat cesareans in 30,000 women:

Increased risks of placenta accreta, hysterectomy, transfusion of 4 units or more of packed red blood cells, [bladder injury], bowel injury, urethral injury, ileus [absence of muscular contractions of the intestine which normally move the food through the system], ICU admission, and longer operative time were seen with an increasing number of cesarean deliveries…. After the first cesarean, increased risk of placenta previa, need for postoperative (maternal) ventilator support, and more hospital days were seen with increasing number of cesarean deliveries…Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

It is quite typical for a woman to receive inflated rates of uterine rupture while the practitioner minimizes the risks of repeat cesarean.  This OB goes one step further and claims there are no risks at all besides the general risks associated with surgery.

It is no wonder that most women ‘chose’ repeat cesareans and only 45% of American women are interested in the option of a VBAC (Declercq, 2006).  What kind of choice is it when you make major medical decisions without even a fraction of accurate information?

There is much discussion and debate about what constitutes informed consent.  However, there is no debate that informed consent fundamentally consists of understanding the risks and benefits of your options.  When a woman only hears the (inflated) risks of option one and the (inaccurate) nonexistent risks of option two, it is clear that her practitioner is trying to influence her final decision by skewing the information provided.

Finally, the OB suggests that the desire to have a vaginal birth and avoid medically unnecessary surgery warrants psychological help:

I flat out said to him that I just cannot have another c-section [without medical indication] and he told me that I need to see a therapist, [that] it’s not that big of a deal and it is the safest way to go!

It might be helpful for this OB, and others who think like him, to learn more about how women are impacted by their cesareans.  Cesareans performed on otherwise healthy babies and healthy moms are absolutely a big deal to many women.  Even when cesareans are medically indicated, there are women who still mourn the loss of a vaginal birth even as they celebrate their healthy baby and the technology that made their entrance into the world safe.  Read American Women Speak About VBAC for more personal stories.

Then the OB makes it sound like he’s the only game in town:

Oh and then at the very end he said I could always go with another provider but he is pretty much the most open to VBAC.  I flat out told him that he is not VBAC friendly at all and that if he is the most open in town I have quite the battle ahead of me.

The emotional fallout of the appointment:

The entire visit I just had to hold back tears and once I hit the street I lost it.  I just want to hit my head against a wall!! I’m just sad, sad that it has to be this way – sad that, as much as I want to have another baby, I dread getting pregnant.  Sad that women are told this shit and forced to believe it.  I’m just in such a funk now…..just a sad, sad funk.

But it’s not just Brooke.

Michelle was told by her OB that uterine rupture rates increase with each VBAC which contradicts a 2008 study that concluded the risk of uterine rupture drops 50% after the first VBAC (Mercer, 2008).  One of the women who attended the VBAC class this past Sunday said that her OB quoted a uterine rupture rate of 6-10% after one prior low transverse cesarean. Sarah was quoted a rate of 10% “after the first section.”  Karla was also quoted 10% and called “selfish” by her OB who was “appalled that [she] would risk the life of [her] baby.”  Once again, the correct rate for uterine rupture in a spontaneous labor after one prior low transverse cesarean is 0.4% (Landon, 2004) and these women are quoted rates 15 – 25 times higher.

Another way doctors lie is by circumventing the risk of VBAC issue entirely.  A friend told me that her doctor said her medical insurance wouldn’t pay for a VBAC.  So believing her doctor and thinking she didn’t have any other option, she had a scheduled repeat cesarean. Turns out, my friend had the same medical insurance as me and that same insurance reimbursed me for my homebirth VBAC.

And who can forget the irate mom who left a comment on the VBACfacts Facebook fan page expressing her disbelief that any “selfish idiot” would pursue a VBAC.  Her OB told her that there was a 10% infant and maternal mortality rate with trials of labor after cesarean.  When I emailed her with the correct rates of 0.02% for maternal mortality and 0.05% for infant death or brain damage (Landon, 2004) and requested she forward any studies supporting a 10% mortality rate, she didn’t reply.

VBAC consults that misinform are all to common and help contribute to the 90% repeat cesarean rate in American (Hamilton, 2009).  If you are a VBAC supportive practitioner, and would like to make it easier for women in your community to find you, please read: How to best connect moms with VBAC supportive practitioners?

Learn more about finding a supportive care provider:

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Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology , 106, 700-6.

Declercq, E. R., & Sakala, C. (2006). Listening to Mothers II: Reports of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection.

Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2009, March 18). Births: Preliminary Data for 2007. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

Huang, W. H., Nakashima, D. K., Rumney, P. J., Keegan, K. A., & Chan, K. (2002). Interdelivery Interval and the Success of Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology , 99, 41-44.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine , 351, 2581-2589.

Landon, M. B., Leindecker, S., Spong, C., Hauth, J., Bloom, S., Varner, M., et al. (2005). The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. American Journal of Obstetrics and Gynecology , 193, 1016-1023.

Landon, M. B., Spong, C. Y., & Tom, E. (2006). Risk of Uterine Rupture With a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery. Obstetrics & Gynecology , 108, 12-20.

Macones, G. A., Cahill, A., Pare, E., Stamilio, D. M., Ratcliffe, S., Stevens, E., et al. (2005). Obstetric outcomes in women with two prior cesarean deliveries: Is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology , 192, 1223-9.

Mercer, B. M., Gilbert, S., Landon, M. B., & Spong, C. Y. (2008). Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstetrics & Gynecology , 11, 285-91.

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated with Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology , 107, 1226-32.

Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. Journal of the American Medical Association , 287 (20), 2684-2690.

Finding VBAC statistics for your hospital and state

Update 4/11/12: Since I wrote this article, the brilliant Jill Arnold from the Unnecesarean started a new website where she shares cesarean rates by hospital: CesareanRates.com.  I would recommend checking this resource first before trying out the strategies I describe below.

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Jeri left this comment at I’m pregnant and want a VBAC, what do I do?:

I want to plan for a VBAC I am not pregnant as of yet but will be ttc in 2 months. I am from La Crosse WI area and they have two hospitals Gunderson Lutheran and Franciscan Skemp..when I called them to get there statistics about VBACs they told me they didn’t have any. So how should I choose which hospital to go to for the better chance of succeeding with my VBAC. I also do not have any doulas in the area is it necessary to have a doula for a successful VBAC? Any thoughts or suggestions would be great. Thank you.

Hi Jeri!

It’s ironic that the person you spoke with at the hospital said that they didn’t have any VBAC statistics, because when I googled “Gundersen Lutheran VBAC,” I found a page entitled “Births by Cesarean and Vaginal Births After Cesarean” on Gundersen Lutheran’s very own website where they state:

A vaginal delivery is the preferred, naturally-designed way to have a baby but when needed, delivery by Cesarean section is a second option. At Gundersen Lutheran, efforts are made to choose a vaginal birth, even after a previous C-section unless there are reasons that would put mother or baby at risk.

“Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.” [ACOG Practice Bulletin #54 2004)

AIMS
1. To have a cesarean section rate below the national rate
2. To have a VBAC rate higher than the national rate

They have succeeded in their goals as Gundersen Lutheran boasted a 27.3% VBAC rate in 2006.  That is exceptional considering that the national average is 9.2% (CDC 2006) and the Wisconsin state average is 12% (Wisconsin: Infant Births and Deaths 2006).

Ted Peck, M.D. is named “activity leader” on that page so I would contact him and ask for the top three VBAC doctors at Gunderson Lutheran.  I would also check out the resources here for additional referrals and to see if any of the names overlap.  Keep in mind that just because the hospital has a great VBAC rate doesn’t mean that all the OBs are supportive of VBAC.  You will still want to ask the same questions and interview a couple different doctors, just like you would get more than one quote if you wanted work done on your house.  You are the consumer, you have the power to chose who you will hire!  It’s important for you to understand the risks and benefits of VBAC vs. repeat cesarean to you, your baby, as well as your future children and health, but be on the look out for scare tactics masquerading as informed consent.

I also googled “Franciscan Skemp VBAC” and was directed to ICAN’s VBAC Hospital Policy Information where Franciscan Skemp is listed as a de facto VBAC ban hospital.  This means that while there is no formal ban in place, the hospital does not attend VBACs.  They could give you a whole list of reasons like, “Our OBs don’t want to do them” or “Our anesthesiologists don’t want to sit in the hospital during a VBAC labor,” but Dr. Stuart Fischbein gives us another perspective:

[Hospitals] ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections—the hospital does, not necessarily the physician, but the hospital does—so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.” But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

(To read more of this interview with Dr. Fischbein, please go to: An Inside Look at Hospitals & VBAC Bans.)

If I was unable to easily find this information by googling, I would have gone to Wisconsin’s Department of Health Services and just start searching for VBAC, birth, cesarean, and hospital statistics to see what I could find.  Sometimes this data is so deep within a website, it can be tricky to locate.  You could also call the Department of Health Services and ask them if they maintain hospital birth statistics.  The state of California maintains this data, but I don’t know if all states do and if they make that information available to the public.

In terms of a doula, yes, I think it’s very important for any woman laboring in a hospital, especially women seeking a VBAC, to have a doula.  (Here is more information on what a doula is and the many benefits of having one: DONA’s Birth Doula FAQs.)  Some practices are not supportive of doulas, even going so far as to post a sign in the waiting room detailing their anti-doula policy.  Switch providers immediately if you read a similar sign or if you discover that your provider is not doula friendly.  A great way to find out is to ask your OB or midwife if they have any doulas they can recommend.  Their response will quickly tell you if this care provider and you have the same vision for your birth.

I went to findadoula.com, and found there was one doula listed for La Cross, WI:

Renee Plunkett

Telephone: 608-786-4466

Location: West Salem Wisconsin United States

I also cover the following geographic areas:
La Crosse, WI

Hopefully you two will be a good fit and if not, the list of resources I provide for finding a supportive OB or midwife can also be used for finding a doula.  I would add DONA and toLabor (formally ALACE) which are Doula credentialing organizations as additional resources.  DONA lists 64 birth doulas and toLabor lists 10 birth doulas in Wisconsin.

You can find more VBAC statistics by going to the The Birth Survey’s State Resources page which provides links to each state’s birth statistics.

For Wisconsin, we have Wisconsin: Infant Births and Deaths, 2006 where we are given the following statistics on page 30:

Delivery Method Number Percentage
Vaginal (no previous C-section) 52,713 72.9%
Primary C-Section 10,342 14.3%
Repeat C-Section 7,418 10.3%
VBAC 1,017 1.4%
Forceps 812 1.1%
Other 0 0.0%
Total Births 72,302 100%

We can determine the VBAC rate by adding the number of Repeat C-Sections (7,418) and VBACs (1,017) together to get a total number of births after cesarean in 2006 (8,435).

By dividing the total number of VBACs (1,017) by the number of births after cesarean (8,435), and multiplying that number by 100, we get the VBAC rate of 12.06%.  This means that 87.9% of women in Wisconsin have repeat cesareans.

Here’s hoping you are in that 12%!

Warmly,

Jen from vbacfacts.com

Lightning - Tucson, AZ

Lightning strikes, shark bites & uterine rupture

Lightning - Tucson, AZWhen someone understates the risk of UR, I think it’s just as important the clarify as it is when someone overstates the risk. How else are women to make an informed decision? Just as it’s plain wrong for an OB to tell a woman with one prior low transverse cesarean that she has a 20% risk of rupture, it’s equally wrong when VBAC advocates say the risk is virtually non-existent.

Over the years, I have heard the statement: “You are more likely to be struck by lightning or bitten by a shark than experience uterine rupture!”

Today I’m going to get the statistics and run the numbers so you can see for yourself how the risk of these events compare.

Uterine Rupture

For this exercise, we will use the uterine rupture (UR) rate based on one prior low transverse (bikini) cut cesarean in a spontaneous labor determined by Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery (Landon 2004):

Risk of uterine rupture: 1/240 or 0.4%
Risk of infant death or oxygen deprivation: 1/2000 or 0.05%

Lightning Strikes

Using the faulty theory I’m going to calculate the number of Floridians, since it is the “lightning strike state,” who would be struck by lightning.

Let’s assume that the risk of getting struck by lightning in Florida is the same as uterine rupture (even though the saying goes the risk is greater): 1 in 240 or 0.4% or 0.00416

With 18,328,340 people living in Florida, that would mean that 76,368 people are struck by lightning every year in Florida. According to the CDC, that is more than the number of Americans who die annually from diabetes (72,449), Alzheimer’s disease (72,432), and influenza and pneumonia (56,326).

Using the National Weather Service stat that 10% of people struck by lightning die, we would have 7,636 people dying in Florida every year from lightning strikes. At that rate, you would have 209 people struck by lightning and 20 of those people dying every day in the state of Florida.

Now, I don’t live in Florida and I’m not an expert in lightning strikes, but that sounds like a lot of people dying.

Now let’s switch our assumptions and use the National Weather Service’s stats.

Odds of being struck by lightning in a given year (reported deaths + injuries) 1/700,000
Odds of being struck by lightning in a given year (estimated total deaths + injuries) 1/400,000

When we turn that fraction into a percentage, we get the following risk of being struck by lightening: 0.00025% – 0.00014%.

Using the National Weather Service’s statistics, we get 26 – 46 annual lightning strike related deaths or injuries in Florida.

Which sounds more reasonable to you? 26-46 Floridians struck annually by lightning or 76,368?

And that is assuming that the rate is the SAME as uterine rupture, but the rumor is that the rate of lightning strikes is HIGHER which means MORE than 76,368 Floridians are struck by lightning every year and more than 20 Floridians are dying daily from lightning strikes.

Now, does that pass the smell test? Does it seem reasonable in the least? It doesn’t to me.

Some would argue that in order to make the comparison, we need to eliminate the number of non-birthing people in Florida, but you really don’t because the lightning strike doesn’t know whether you are a man, woman, child, or menopausal. A Floridian women with one prior cesarean in spontaneous labor has the same risk as everyone else to be struck by lightning: 0.00025% – 0.00014%.

Shark Bites

From the Florida Museum of Natural History:

What are the chances of being attacked by a shark?

The chances of being attacked by a shark are very small compared to other animal attacks, natural disasters, and ocean-side dangers. Many more people drown in the ocean every year than are bitten by sharks. The few attacks that occur every year are an excellent indication that sharks do not feed on humans and that most attacks are simply due to mistaken identity. For more information on the relative risk of shark attacks to humans click HERE.

How many people are attacked each year by sharks?

Worldwide there is an average of 50-70 shark attacks every year. The number of attacks has been increasing over the decades as a result of increased human populations and the use of the oceans for recreational activity. As long as humans continue to enter the sharks’ environment, there will be shark attacks. For more information on shark attack statistics click HERE.

We have about 6.5 billion people on the world and 50-70 get bit by a shark annually which works out to 0.00000077% – 0.00000108%.

But this whole discussion is moot because it’s poor statistics to even compare these events (UR & lightning strikes or shark bites) because they are totally different types of occurrences.

The Actual Figures

This is a great chart from the Floria Museum of Natural History website entitled “A Comparison of Unprovoked Shark Attacks with the Number of Lightning Fatalities in Coastal United States: 1959-2008” where they show even in the state of Florida, over the past 49 years, there have been a mere 453 lightning fatalities and 585 shark bites. Remember that over 7,600 Floridans would be dying annually if the rate of uterine rupture was the same as the rate of lightning strikes.

Comparing Risks

There are some major problems when one is trying to compare risks of differing events.

One problem is when one uses a lifetime risk statistic as a means for comparison. You simply cannot take a statistic, like your lifetime risk of being struck by lightning (1 in 5000 which is significantly lower than one’s annual risk,) and compare that to your one-time risk of uterine rupture. If anything, using the annual risk of lightning strikes would be more accurate, but it still would be a false comparison.

An article by Andrew Pleasant entitled, Communicating statistics and risk, elaborates:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

The second major problem is often the two things you are comparing are so different that the comparison is worthless. Again, I defer to Mr. Pleasant:

Try not to compare unlike risks. For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different. When people assess risks and make decisions, they usually consider how much control they have over the risk. Driving is a voluntary risk that people feel (correctly or not) that they can control. This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate. The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Going Forward

It can be hard when wading through the (mis)information available on the internet about VBAC, but here are some tips to help you out.

1. Always find the source – If you find some great statistic, but there is no source referenced, be wary.

2. Verify the statistic – If there is a source listed, read through it. If there is no source listed, do a quick Google search. It didn’t take me long at all to find all the statistics in this article and run the math.

3. Leave a comment – If you find something on the internet that doesn’t pass the smell test, leave a comment on the blog or email the author asking for the source.

4. Be careful about forwarding things – There is so much misinformation on the internet, so do your friends a favor and don’t forward them emails or articles unless you have verified the information to be true. That is one way to quickly nip falsehoods in the bud!

For further reading on using statistics, check out, Correlation and Causation:Misuse and Misconception of Statistical Facts and Risk Communication, Risk Statistics, and Risk Comparisons: A Manual for Plant Managers

Monterey County hospital reverses VBAC ban

This is great!  A hospital reversing their VBAC ban!  I really wish articles like this would talk less about "the experience" and more about the life-long benefits of vaginal birth for mom and baby. 

May 28, 2009

Natural birth after c-section possible at NMC again

By Leslie Griffy
lgriffy@thecalifornian.com

Monterey County women who’ve had a c-section don’t have to leave the county to give birth naturally anymore.

Natividad Medical Center announced Wednesday that so-called VBACs vaginal birth after cesarean are back.

Like hospitals throughout the country, those in the county dropped the practice of allowing women who have had cesarean sections to give birth vaginally because of a slight increase in complications for such births. Still demand for the service was there.

"This is something that I’ve heard women wanting for as long as I’ve lived here," said Judy Rasmussen, the hospital’s director of prenatal services.

Increasingly, expectant mothers are pushing for natural birth over c-sections. But many women who have had caesareans in the past were told they’d not be able to find a hospital to give birth naturally.

When Cindy Laurance gave birth to her second child in 1990, she hunted for a place to have her daughter through VBAC and ended up at Natividad, then one of the few to provide the service.

"I wanted the experience of natural birth," she said. "You are much more present when you don’t have a lot of drugs in you."

Her first born, Alex McCloskey, didn’t nurse right away because of the drugs required for the c-section, Laurance said. It was different with daughter Anna, born using VBAC. Her own healing time, Laurance said, was much quicker, and she was empowered by experiencing the birthing process.

"VBAC is a really good opportunity for women to have the experience has nature intended," Laurance said.

Natividad’s insurer, BETA Healthcare, approved the facility for the procedure. It required the hospital to have an obstetrician and anesthesiologist at the hospital 24 hours a day, as well as an operating room on standby should something go wrong, said Dr. Peter Chandler.

"You can’t wait for doctors to come in from home," Chandler said. Natividad had met those requirements for the past year.

The announcement won plaudits from the Birth Network of Monterey County, a group that aims to education families about birthing options.

"The old adage ‘Once a c-section, always a c-section’ no longer holds true," said the group’s Joy Weston.

For more information, call 831-755-4156.


VBAC & Cesarean Rates of California Hospitals, 2007

This information is so important for any woman seeking VBAC.  It’s not enough that your hospital “allows” VBAC.  In order to see how supportive that hospital is of vaginal birth, you need to know what their VBAC rate is in addition to their primary CS rate.  Be sure to read, “Why if your hospital ‘allows’ VBAC isn’t enough” for more information as well as I’m pregnant and want a VBAC, what do I do?.

From 2006 to 2007, the total cesarean rate increased from 27.9% to 28.8% and the primary cesarean rate grew from 16.6% to 17.1 whereas the overall VBAC rate decreased from 8.9% to 8.1%.

You can also read excerpts from a January 2008 press release from the California Office of Statewide Health Planning and Development (OSHPD) where they categorize cesarean section and primary cesarean section as “POSSIBLE OVER UTILIZATION” and VBAC as “POSSIBLE UNDER UTILIZATION” here.  On that same page, OSHPD further describes how they categorized cesareans vs. VBACs:

  • Cesarean Delivery Rate
    Number of Cesarean Section Deliveries per 100 Deliveries (excludes abnormal presentation, preterm birth, fetal death, multiple gestations, and breech procedure). Cesarean delivery may be overused in some facilities, so lower rates may represent better care.
  • Cesarean Delivery Rate – Primary
    Number of Cesarean Deliveries per 100 deliveries among women who have not previously had a Cesarean section (excludes abnormal presentation, preterm, fetal death, multiple gestation, and breech procedures). Cesarean delivery may be overused in some facilities, so lower rates may represent better care.
  • Vaginal Birth After Cesarean (VBAC) Rate
    Number of vaginal births per 100 women with a previous Cesarean delivery. VBAC may be underused in some facilities, so higher rates may represent better care, though this rate includes some women who were probably not good candidates for vaginal birth.
  • Vaginal Birth After Cesarean (VBAC) Rate, Uncomplicated
    Number of vaginal births per 100 women with a previous Cesarean delivery (excludes abnormal presentation, preterm birth, fetal death, multiple gestation, and breech procedures). VBAC may be underused in some facilities, so higher rates may represent better care.

Below, I will use the VBAC Rate which includes all VBACs performed at that hospital.

Top 5 California Hospitals: VBACs Performed 2007

  1. Santa Clara Valley Medical Center – 289
  2. Alta Bates Summit Medical Center – Alta Bates Campus – 227
  3. California Hospital Medical Center – Los Angeles – 160
  4. Kaiser Fnd Hosp – South Sacramento – 133
  5. Sutter Memorial Hospital – 123

Top 5 California Hospitals: VBAC Rate 2007

  1. San Francisco General Hospital – 33.0% (53 VBACs)
  2. Kaiser Fnd Hosp – Redwood City – 32.1% (42 VBACs)
  3. Kaiser Fnd Hosp – South Sacramento – 31.7% (133 VBACs)
  4. Santa Clara Valley Medical Center  – 31.3% (289 VBACs)
  5. Seton Medical Center – 28.8% (20 VBACs)

Top 5 Hospitals: Primary Cesareans Performed 2007

  1. Sharp Mary Birch Hospital For Women – 1338 (22.2%)
  2. Cedars Sinai Medical Center – 1,231 (21.0%)
  3. Citrus Valley Medical Center – Qv Campus – 1,173 (30.7%)
  4. St. Francis Medical Center – 1,054 (21.8%)
  5. Pomona Valley Hospital Medical Center – 1,003 (17.7%)

Top 5 Hospitals: Overall Cesareans Performed 2007

  1. Sharp Mary Birch Hospital For Women – 2,469 (33.4%)
  2. Pomona Valley Hospital Medical Center – 2,318 (34.0%)
  3. Citrus Valley Medical Center – Qv Campus – 2,178 (46.4%)
  4. St. Francis Medical Center – 2,114 (37.1%)
  5. Cedars Sinai Medical Center – 1,968 (27.9%)

Top 6 Hospitals: Overall Cesarean Rate 2007

  1. Stanford Hospital – 89.1% (4 CS)
  2. Los Angeles Community Hospital-62.2% (341 CS)
  3. East Valley Hospital Medical Center – 58.3% (204 CS)
  4. Community And Mission Hsp Of Hntg Park – Slauson – 51.8% (735 CS)
  5. El Centro Regional Medical Center – 48.2% (641 CS)
  6. Pacifica Hospital Of The Valley – 48.0% (453 CS)

Inland Empire Hospitals – VBAC vs. Primary CS Rates

  1. Loma Linda University Medical Center – 15.8% vs. 16.2%
  2. Kaiser Fnd Hosp – Riverside – 15.7% vs. 16.2%
  3. Kaiser Fnd Hosp – Fontana – 13.5% vs. 12.4%
  4. Riverside County Regional Medical Center – 7.3% vs. 9.9%
  5. St. Bernardine Medical Center – 5.9% vs. 10.8%
  6. Pomona Valley Hospital Medical Center – 4.2% vs.  17.7%
  7. St. Mary Regional Medical Center – 2.2% vs. 9.1%
  8. Hi-Desert Medical Center – 1.4% vs. 23.6%
  9. Redlands Community Hospital – 1.4% vs. 15.3%
  10. Parkview Community Hospital Medical Center – 1.3% vs. 20.2%
  11. Corona Regional Medical Center – Main – 1.0% vs. 16.4%
  12. Community Hospital Of San Bernardino – 0.8% vs. 28.6%
  13. Montclair Hospital Medical Center – 0.6% vs. 27.2%
  14. San Antonio Community Hospital – 0.5% vs. 25.3%
  15. Hemet Valley Medical Center – 0.4% vs. 31.4%
  16. Riverside Community Hospital – 0.2% vs. 19.0%
  17. Mountains Community Hospital – 0.0% vs. 16.4%
  18. Eisenhower Memorial Hospital – No births reported
    Chino Valley Medical Center – No births reported
    Kindred Hospital Ontario – No births reported

Hospitals with VBAC Bans?  All these hospitals had 5 or fewer VBACs in 2007.  I wonder if it is because they have banned them.  There are 257 hospitals that reported births and the 109 listed below represents 42.4% of them (up from 39% in 2006).  I guess they should read this and this.

  1. Anaheim General Hospital
  2. Banner Lassen Medical Center
  3. Barstow Community Hospital
  4. Barton Memorial Hospital
  5. Bellflower Medical Center
  6. Beverly Hospital
  7. Central Valley General Hospital
  8. Coalinga Regional Medical Center
  9. Coastal Communities Hospital
  10. Colusa Regional Medical Center
  11. Community Hospital Monterey Peninsula
  12. Community Hospital Of San Bernardino
  13. Corona Regional Medical Center – Main
  14. Delano Regional Medical Center
  15. Desert Valley Hospital
  16. Doctors Hospital Of Manteca
  17. East Los Angeles Doctors Hospital
  18. East Valley Hospital Medical Center
  19. Eden Medical Center
  20. El Centro Regional Medical Center
  21. Fairchild Medical Center
  22. Feather River Hospital
  23. Foothill Presbyterian Hospital-Johnston Memorial
  24. French Hospital Medical Center
  25. George L Mee Memorial Hospital
  26. Goleta Valley Cottage Hospital
  27. Greater El Monte Community Hospital
  28. Hazel Hawkins Memorial Hospital
  29. Hemet Valley Medical Center
  30. Henry Mayo Newhall Memorial Hospital
  31. Hi-Desert Medical Center
  32. John F Kennedy Memorial Hospital
  33. La Palma Intercommunity Hospital
  34. Little Company Of Mary – San Pedro Hospital
  35. Lodi Memorial Hospital
  36. Lompoc Healthcare District
  37. Los Angeles Community Hospital
  38. Los Angeles Metropolitan Med Ctr
  39. Mammoth Hospital
  40. Marshall Medical Center (1-Rh)
  41. Los Angeles Co Martin Luther King Jr/Drew Med Ctr
  42. Mayers Memorial Hospital
  43. Memorial Hospital Los Banos
  44. Memorial Hospital Medical Center – Modesto
  45. Memorial Hospital Of Gardena
  46. Mendocino Coast District Hospital
  47. Mercy Medical Center
  48. Mercy Medical Center Mt. Shasta
  49. Modoc Medical Center
  50. Montclair Hospital Medical Center
  51. Monterey Park Hospital
  52. Moreno Valley Community Hospital
  53. Mountains Community Hospital
  54. North Bay Medical Center
  55. Northern Inyo Hospital
  56. Oak Valley District Hospital (2-Rh)
  57. Oroville Hospital
  58. Pacific Alliance Medical Center, Inc.
  59. Pacific Hospital Of Long Beach
  60. Pacifica Hospital Of The Valley
  61. Palo Verde Hospital
  62. Paradise Valley Hospital
  63. Parkview Community Hospital Medical Center
  64. Petaluma Valley Hospital
  65. Pioneers Memorial Hospital
  66. Plumas District Hospital
  67. Pomerado Hospital
  68. Providence Holy Cross Medical Center
  69. Redbud Community Hospital
  70. Redlands Community Hospital
  71. Regional Medical Of San Jose
  72. Ridgecrest Regional Hospital
  73. Riverside Community Hospital
  74. Salinas Valley Memorial Hospital
  75. San Antonio Community Hospital
  76. San Dimas Community Hospital
  77. San Gorgonio Memorial Hospital
  78. San Ramon Regional Medical Center
  79. Santa Barbara Cottage Hospital
  80. Santa Monica – Ucla Medical Center
  81. Sierra Kings District Hospital
  82. Sierra Nevada Memorial Hospital
  83. Sierra View District Hospital
  84. Simi Valley Hospital And Health Care Svcs-Sycamore
  85. Sonoma Valley Hospital
  86. Sonora Regional Medical Center – Greenley
  87. St. Elizabeth Community Hospital
  88. St. Helena Hospital
  89. St. John’s Pleasant Valley Hospital
  90. St. John’s Regional Medical Center
  91. St. Joseph Hospital – Eureka
  92. St. Louise Regional Hospital
  93. St. Rose Hospital
  94. Stanford Hospital
  95. Sutter Amador Hospital
  96. Sutter Auburn Faith Hospital
  97. Sutter Coast Hospital
  98. Sutter Davis Hospital
  99. Sutter Medical Center Of Santa Rosa
  100. Sutter Tracy Community Hospital
  101. Tahoe Forest Hospital
  102. Tulare District Hospital
  103. Twin Cities Community Hospital
  104. Valley Memorial Hospital – Livermore
  105. Verdugo Hills Hospital
  106. Victor Valley Community Hospital
  107. Western Medical Center Hospital – Anaheim
  108. Whittier Hospital Medical Center
  109. Woodland Memorial Hospital

Utilization Rates* for Selected Medical Procedures in California Hospitals, 2007
Office of Statewide Health Planning and Development, Hospital Patient Data**
  (Here is the info as a Adobe Acrobat PDF for easy printing.)

      

  Hospital Total CS # Total CS % Primary CS # Primary CS % VBAC Uncomp # VBAC Uncomp % VBAC # VBAC %
  Statewide 140,559 28.8 70,889 17.1 6,289 8.3 7,034 8.1
Alameda ALAMEDA CO MED CTR – HIGHLAND CAMPUS 253 20.2 126 11.3 50 27.7 55 27.3
Alameda ALAMEDA HOSPITAL . . . . . . . .
Alameda ALTA BATES SUMMIT MED CTR-ALTA BATES CAMPUS 1634 22.5 814 13.2 209 20.4 227 19.2
Alameda ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS-HAWTHORNE . . . . . . . .
Alameda CHILDRENS HOSPITAL AND RESEARCH CTR AT OAKLAND . . . . . . . .
Alameda EDEN MEDICAL CENTER 231 25.2 122 15.3 0 0.0 1 0.7
Alameda KAISER FND HOSP – FREMONT . . . . . . . .
Alameda KAISER FND HOSP – HAYWARD 689 24.1 415 17.0 83 23.3 90 22.8
Alameda KAISER FND HOSP – OAKLAND CAMPUS 607 25.0 352 17.0 52 17.2 59 17.4
Alameda KINDRED HOSPITAL – SAN FRANCISCO BAY AREA . . . . . . . .
Alameda SAN LEANDRO HOSPITAL . . . . . . . .
Alameda ST. ROSE HOSPITAL 247 26.9 129 15.6 2 1.6 2 1.4
Alameda VALLEY MEMORIAL HOSPITAL – LIVERMORE 442 30.5 241 20.0 3 1.5 4 1.7
Alameda WASHINGTON HOSPITAL – FREMONT 702 24.8 351 14.8 27 7.2 34 8.2
Amador SUTTER AMADOR HOSPITAL 65 25.6 33 14.3 1 3.0 2 4.3
Butte BIGGS GRIDLEY MEMORIAL HOSPITAL . . . . . . . .
Butte ENLOE MEDICAL CENTER- ESPLANADE CAMPUS 339 24.7 183 14.9 7 4.3 7 3.9
Butte FEATHER RIVER HOSPITAL 182 25.4 98 15.0 1 1.2 2 1.9
Butte OROVILLE HOSPITAL 143 30.1 65 15.2 3 3.6 4 3.9
Calaveras MARK TWAIN ST. JOSEPH’S HOSPITAL . . . . . . . .
Colusa COLUSA REGIONAL MEDICAL CENTER 72 38.0 39 23.8 0 0.0 0 0.0
Contra Costa CONTRA COSTA REGIONAL MEDICAL CENTER 423 22.0 220 12.8 80 27.9 87 26.7
Contra Costa DOCTORS MEDICAL CENTER – SAN PABLO . . . . . . . .
Contra Costa JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS . . . . . . . .
Contra Costa JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS 624 22.7 276 12.6 56 14.2 58 13.0
Contra Costa KAISER FND HOSP – RICHMOND CAMPUS . . . . . . . .
Contra Costa KAISER FND HOSP – WALNUT CREEK 994 23.4 569 15.8 79 15.8 81 13.9
Contra Costa KAISER FOUND HSP-ANTIOCH 28 20.7 17 13.6 0 0.0 0 0.0
Contra Costa SAN RAMON REGIONAL MEDICAL CENTER 261 34.8 148 25.0 0 0.0 0 0.0
Contra Costa SUTTER DELTA MEDICAL CENTER 207 23.5 97 12.6 12 9.8 12 8.4
Del Norte SUTTER COAST HOSPITAL 62 20.4 32 11.0 0 0.0 0 0.0
El Dorado BARTON MEMORIAL HOSPITAL 140 29.8 73 18.0 1 1.5 2 2.7
El Dorado MARSHALL  MEDICAL CENTER (1-RH) 163 29.2 88 17.9 4 5.0 5 5.8
Fresno COALINGA REGIONAL MEDICAL CENTER 0 0.0 0 0.0 . 0.0 0 0.0
Fresno COMMUNITY MEDICAL CENTER – CLOVIS 975 32.9 470 19.4 34 6.3 38 6.4
Fresno COMMUNITY REGIONAL MEDICAL CENTER-FRESNO 1563 29.0 645 13.8 72 7.2 95 7.8
Fresno FRESNO HEART AND SURGICAL HOSPITAL . . . . . . . .
Fresno FRESNO SURGICAL HOSPITAL . . . . . . . .
Fresno KAISER FND HOSP – FRESNO 289 23.9 147 14.4 43 23.1 44 20.7
Fresno KINGSBURG MEDICAL CENTER . . . . . . . .
Fresno SAN JOAQUIN VALLEY REHABILITATION HOSPITAL . . . . . . . .
Fresno SIERRA KINGS DISTRICT HOSPITAL 498 36.5 229 19.9 0 0.0 0 0.0
Fresno ST. AGNES MEDICAL CENTER 1207 34.3 649 21.4 24 4.1 28 4.2
Fresno UNIVERSITY MEDICAL CENTER . . . . . . . .
Glenn GLENN MEDICAL CENTER . . . . . . . .
Humboldt JEROLD PHELPS COMMUNITY HOSPITAL . . . . . . . .
Humboldt MAD RIVER COMMUNITY HOSPITAL 118 23.1 75 16.4 13 23.0 14 22.8
Humboldt REDWOOD MEMORIAL HOSPITAL 62 22.4 22 9.1 6 12.8 6 12.8
Humboldt ST. JOSEPH HOSPITAL – EUREKA 180 31.6 97 19.4 0 0.0 0 0.0
Imperial EL CENTRO REGIONAL MEDICAL CENTER 641 48.2 340 32.4 3 1.0 3 0.9
Imperial PIONEERS MEMORIAL HOSPITAL 386 28.6 162 13.7 1 0.4 1 0.4
Inyo NORTHERN INYO HOSPITAL 55 31.6 26 17.3 0 0.0 0 0.0
Inyo SOUTHERN INYO HOSPITAL . . . . . . . .
Kern BAKERSFIELD HEART HOSPITAL . . . . . . . .
Kern BAKERSFIELD MEMORIAL HOSPITAL- 34TH STREET 501 24.1 178 9.7 29 8.1 32 8.1
Kern DELANO REGIONAL MEDICAL CENTER 215 26.2 71 10.0 1 0.7 1 0.6
Kern GOOD SAMARITAN HOSPITAL-BAKERSFIELD . . . . . . . .
Kern KERN MEDICAL CENTER 820 24.5 281 9.8 99 15.3 113 14.9
Kern KERN VALLEY HEALTHCARE DISTRICT . . . . . . . .
Kern MERCY HOSPITAL – BAKERSFIELD 754 23.2 374 13.3 80 17.1 89 16.6
Kern RIDGECREST REGIONAL HOSPITAL 180 39.3 88 22.8 3 3.1 3 2.8
Kern SAN JOAQUIN COMMUNITY HOSPITAL 497 21.9 188 9.1 29 8.5 29 8.1
Kern TEHACHAPI HOSPITAL . . . . . . . .
Kings CENTRAL VALLEY GENERAL HOSPITAL 690 37.3 309 20.0 0 0.0 1 0.2
Kings CORCORAN DISTRICT HOSPITAL . . . . . . . .
Kings HANFORD COMMUNITY MEDICAL CENTER 299 34.4 146 19.5 5 3.1 7 3.8
Lake REDBUD COMMUNITY HOSPITAL 35 23.1 9 6.7 2 6.9 2 6.9
Lake SUTTER LAKESIDE HOSPITAL 98 31.4 56 20.5 7 14.2 7 12.4
Lassen BANNER LASSEN MEDICAL CENTER 58 28.4 25 14.0 2 5.6 2 5.5
Los Angeles ALHAMBRA HOSPITAL . . . . . . . .
Los Angeles ANTELOPE VALLEY HOSPITAL 1565 31.1 750 17.2 14 1.7 19 2.1
Los Angeles BARLOW RESPIRATORY HOSPITAL . . . . . . . .
Los Angeles BELLFLOWER MEDICAL CENTER 597 39.6 322 25.2 0 0.0 1 0.3
Los Angeles BEVERLY HOSPITAL 478 36.4 226 20.3 0 0.0 0 0.0
Los Angeles BROTMAN MEDICAL CENTER . . . . . . . .
Los Angeles CALIFORNIA HOSPITAL MEDICAL CENTER – LOS ANGELES 1045 28.7 532 16.9 133 20.4 160 20.8
Los Angeles CATALINA ISLAND MEDICAL CENTER . . . . . . . .
Los Angeles CEDARS SINAI MEDICAL CENTER 1968 27.9 1231 21.0 100 12.3 112 12.3
Los Angeles CENTINELA FREEMAN REG MED CTR-MARINA CAMPUS . . . . . . . .
Los Angeles CENTINELA HOSPITAL MEDICAL CENTER 848 33.3 395 18.5 28 5.8 30 5.3
Los Angeles CENTURY CITY DOCTORS HOSPITAL . . . . . . . .
Los Angeles CHILDREN’S HOSPITAL OF LOS ANGELES . . . . . . . .
Los Angeles CITRUS VALLEY MEDICAL CENTER – IC CAMPUS . . . . . . . .
Los Angeles CITRUS VALLEY MEDICAL CENTER – QV CAMPUS 2178 46.4 1173 30.7 10 1.0 14 1.2
Los Angeles CITY OF ANGELS MEDICAL CENTER-DOWNTOWN CAMPUS . . . . . . . .
Los Angeles CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL . . . . . . . .
Los Angeles COAST PLAZA DOCTORS HOSPITAL . . . . . . . .
Los Angeles COMMUNITY AND MISSION HSP OF HNTG PK – SLAUSON 735 51.8 384 35.2 9 2.5 9 2.3
Los Angeles COMMUNITY HOSPITAL OF LONG BEACH . . . . . . . .
Los Angeles DOCTORS HOSPITAL OF WEST COVINA, INC . . . . . . . .
Los Angeles DOWNEY REGIONAL MEDICAL CENTER 344 22.6 149 11.4 27 12.1 30 11.5
Los Angeles EARL AND LORRAINE MILLER CHILDRENS HOSPITAL 1391 29.2 643 16.4 104 12.2 121 11.7
Los Angeles EAST LOS ANGELES DOCTORS HOSPITAL 318 46.4 142 26.6 1 0.6 1 0.5
Los Angeles EAST VALLEY HOSPITAL MEDICAL CENTER 204 58.3 113 42.3 0 0.0 0 0.0
Los Angeles ENCINO-TARZANA REGIONAL MED CTR-ENCINO . . . . . . . .
Los Angeles ENCINO-TARZANA REGIONAL MED CTR-TARZANA 611 29.8 326 20.1 16 5.5 17 5.3
Los Angeles FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL 278 40.6 147 27.3 1 0.8 1 0.7
Los Angeles GARFIELD MEDICAL CENTER 1226 37.0 607 23.3 13 2.1 14 1.9
Los Angeles GLENDALE ADVENTIST MEDICAL CENTER – WILSON TERRACE 760 34.6 427 23.4 23 6.4 26 6.2
Los Angeles GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER 487 30.5 224 17.0 14 5.1 14 4.5
Los Angeles GOOD SAMARITAN HOSPITAL-LOS ANGELES 1306 26.7 641 15.6 44 6.2 52 6.5
Los Angeles GREATER EL MONTE COMMUNITY HOSPITAL 171 30.9 57 12.5 0 0.0 1 0.8
Los Angeles HENRY MAYO NEWHALL MEMORIAL HOSPITAL 370 28.5 173 16.4 1 0.5 2 0.9
Los Angeles HOLLYWOOD COMMUNITY HOSPITAL OF HOLLYWOOD . . . . . . . .
Los Angeles HOLLYWOOD PRESBYTERIAN MEDICAL CENTER 1512 38.3 843 25.1 50 6.9 56 6.8
Los Angeles HUNTINGTON MEMORIAL HOSPITAL 1024 31.9 572 21.9 18 3.9 20 3.7
Los Angeles KAISER FND HOSP – BALDWIN PARK 676 22.8 329 13.3 82 19.3 89 18.7
Los Angeles KAISER FND HOSP – BELLFLOWER 703 23.5 380 14.9 110 25.4 118 23.4
Los Angeles KAISER FND HOSP – HARBOR CITY 455 25.9 239 16.4 47 18.0 49 17.2
Los Angeles KAISER FND HOSP – PANORAMA CITY 409 29.4 245 20.9 31 15.9 38 15.5
Los Angeles KAISER FND HOSP – SUNSET 673 32.1 437 24.8 41 15.0 44 14.2
Los Angeles KAISER FND HOSP – WEST LA 317 23.0 181 15.2 29 17.7 32 16.5
Los Angeles KAISER FND HOSP – WOODLAND HILLS 390 22.6 202 14.2 51 21.6 59 21.7
Los Angeles KINDRED HOSPITAL – LA MIRADA . . . . . . . .
Los Angeles KINDRED HOSPITAL – LOS ANGELES . . . . . . . .
Los Angeles LAC/RANCHO LOS AMIGOS NATIONAL REHAB CENTER . . . . . . . .
Los Angeles LAKEWOOD REGIONAL MEDICAL CENTER . . . . . . . .
Los Angeles LANCASTER COMMUNITY HOSPITAL . . . . . . . .
Los Angeles LITTLE COMPANY OF MARY – SAN PEDRO HOSPITAL 185 25.4 75 11.6 1 0.9 1 0.8
Los Angeles LITTLE COMPANY OF MARY HOSPITAL 713 28.6 441 20.6 5 1.8 6 2.0
Los Angeles LONG BEACH MEMORIAL MEDICAL CENTER . . . . . . . .
Los Angeles LOS ANGELES CO HARBOR-UCLA MEDICAL CENTER 274 28.9 158 19.1 26 18.3 29 18.0
Los Angeles LOS ANGELES CO USC MEDICAL CENTER 394 31.2 191 18.8 44 17.9 54 17.7
Los Angeles LOS ANGELES COMMUNITY HOSPITAL 341 62.2 206 48.4 2 1.4 2 1.4
Los Angeles LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER 245 28.2 97 14.3 52 25.7 57 24.0
Los Angeles LOS ANGELES METROPOLITAN MEDICAL CENTER 340 35.2 158 19.5 1 0.5 1 0.5
Los Angeles MARTIN LUTHER KING JR.-HARBOR HOSPITAL 40 31.8 20 19.0 2 9.2 4 16.9
Los Angeles MEMORIAL HOSPITAL OF GARDENA 571 41.2 275 24.3 0 0.0 0 0.0
Los Angeles METHODIST HOSPITAL OF SOUTHERN CALIFORNIA 568 26.5 307 16.9 19 6.8 24 7.2
Los Angeles MIRACLE MILE MEDICAL CENTER . . . . . . . .
Los Angeles MISSION COMMUNITY HOSPITAL – PANORAMA CAMPUS . . . . . . . .
Los Angeles MONTEREY PARK HOSPITAL 656 42.7 331 26.2 0 0.0 0 0.0
Los Angeles MOTION PICTURE AND TELEVISION HOSPITAL . . . . . . . .
Los Angeles NORTHRIDGE HOSPITAL MEDICAL CENTER 881 34.9 424 20.7 9 1.9 11 2.1
Los Angeles NORWALK COMMUNITY HOSPITAL . . . . . . . .
Los Angeles OLYMPIA MEDICAL CENTER . . . . . . . .
Los Angeles PACIFIC ALLIANCE MEDICAL CENTER, INC. 726 37.5 366 22.3 5 1.4 5 1.3
Los Angeles PACIFIC HOSPITAL OF LONG BEACH 377 33.1 105 11.4 1 0.4 1 0.3
Los Angeles PACIFICA HOSPITAL OF THE VALLEY 453 48.0 248 32.8 1 0.5 1 0.4
Los Angeles POMONA VALLEY HOSPITAL MEDICAL CENTER 2318 34.0 1003 17.7 55 4.0 64 4.2
Los Angeles PRESBYTERIAN INTERCOMMUNITY HOSPITAL 954 29.2 474 17.5 51 9.6 63 10.4
Los Angeles PROMISE HOSPITAL OF EAST LOS ANGELES-EAST L.A. CAMPUS . . . . . . . .
Los Angeles PROVIDENCE HOLY CROSS MEDICAL CENTER 825 34.6 461 22.1 1 0.3 1 0.2
Los Angeles PROVIDENCE SAINT JOSEPH MEDICAL CENTER 869 29.6 500 19.6 9 2.4 9 2.0
Los Angeles SAN DIMAS COMMUNITY HOSPITAL 188 25.3 85 13.8 1 1.0 1 0.9
Los Angeles SAN GABRIEL VALLEY MEDICAL CENTER 723 32.1 360 19.8 11 3.0 13 3.0
Los Angeles SANTA MONICA – UCLA MEDICAL CENTER & ORTHOPAEDIC HOSPIT 490 34.6 278 25.0 3 1.4 3 1.3
Los Angeles SHERMAN OAKS HOSPITAL . . . . . . . .
Los Angeles SHRINERS HOSPITAL FOR  CHILDREN – L.A. . . . . . . . .
Los Angeles ST. FRANCIS MEDICAL CENTER 2114 37.1 1054 21.8 94 8.0 111 8.2
Los Angeles ST. JOHN’S HEALTH CENTER 510 25.1 339 19.6 9 5.3 9 4.6
Los Angeles ST. MARY MEDICAL CENTER 751 28.9 393 17.1 29 7.4 31 7.2
Los Angeles ST. VINCENT MEDICAL CENTER . . . . . . . .
Los Angeles TEMPLE COMMUNITY HOSPITAL . . . . . . . .
Los Angeles TORRANCE MEMORIAL MEDICAL CENTER 1248 34.7 634 22.5 15 2.4 15 2.1
Los Angeles TRI-CITY REGIONAL MEDICAL CENTER . . . . . . . .
Los Angeles UCLA MEDICAL CENTER 415 23.9 242 16.5 60 25.9 61 23.4
Los Angeles USC KENNETH NORRIS, JR. CANCER HOSPITAL . . . . . . . .
Los Angeles USC UNIVERSITY HOSPITAL . . . . . . . .
Los Angeles VALLEY PRESBYTERIAN HOSPITAL 1887 39.6 932 23.7 26 2.6 29 2.5
Los Angeles VERDUGO HILLS HOSPITAL 305 33.8 184 25.2 0 0.0 0 0.0
Los Angeles VISTA HOSPITAL OF SAN GABRIEL VALLEY . . . . . . . .
Los Angeles VISTA HOSPITAL OF SOUTH BAY . . . . . . . .
Los Angeles WEST HILLS HOSPITAL AND MEDICAL CENTER 424 34.3 230 23.7 6 3.1 6 2.9
Los Angeles WHITE MEMORIAL MEDICAL CENTER 821 34.4 427 21.5 70 14.9 84 14.4
Los Angeles WHITTIER HOSPITAL MEDICAL CENTER 606 31.8 288 17.8 2 0.6 2 0.6
Madera CHILDREN’S HOSPITAL CENTRAL CALIFORNIA . . . . . . . .
Madera MADERA COMMUNITY HOSPITAL 464 28.3 211 14.7 20 7.3 22 6.9
Marin KAISER FND HOSP – SAN RAFAEL . . . . . . . .
Marin KENTFIELD REHABILITATION HOSPITAL . . . . . . . .
Marin MARIN GENERAL HOSPITAL 360 21.4 189 13.4 51 23.5 56 20.9
Marin NOVATO COMMUNITY HOSPITAL . . . . . . . .
Mariposa JOHN C FREMONT HEALTHCARE DISTRICT . . . . . . . .
Mendocino FRANK R HOWARD MEMORIAL HOSPITAL . . . . . . . .
Mendocino MENDOCINO COAST DISTRICT HOSPITAL 34 22.9 21 15.1 0 0.0 0 0.0
Mendocino UKIAH VALLEY MEDICAL CENTER/HOSPITAL DRIVE 172 23.1 94 14.1 19 19.5 19 17.7
Merced MEMORIAL HOSPITAL LOS BANOS 160 25.7 50 9.4 1 0.9 1 0.8
Merced MERCY MEDICAL CENTER MERCED-COMMUNITY CAMPUS 609 26.2 249 12.2 14 3.7 17 3.9
Modoc MODOC MEDICAL CENTER 0 0.0 0 0.0 0 0.0 0 0.0
Modoc SURPRISE VALLEY COMMUNITY HOSPITAL . . . . . . . .
Mono MAMMOTH HOSPITAL 38 31.6 17 17.4 0 0.0 0 0.0
Monterey COMMUNITY HOSPITAL MONTEREY PENINSULA 345 27.2 190 17.6 2 1.3 2 1.2
Monterey GEORGE L MEE MEMORIAL HOSPITAL 174 31.0 73 15.1 1 1.0 2 1.7
Monterey NATIVIDAD MEDICAL CENTER 592 29.6 223 12.9 5 1.3 7 1.6
Monterey SALINAS VALLEY MEMORIAL HOSPITAL 679 30.6 311 16.5 1 0.3 2 0.5
Napa N M HOLDERMAN MEMORIAL HOSPITAL (VET’S HOME OF CAL . . . . . . . .
Napa QUEEN OF THE VALLEY HOSPITAL – NAPA 191 21.6 88 11.3 15 12.6 19 14.4
Napa ST. HELENA HOSPITAL 81 29.3 40 17.5 0 0.0 0 0.0
Nevada SIERRA NEVADA MEMORIAL HOSPITAL 107 25.9 62 16.5 2 4.2 2 3.7
Nevada TAHOE FOREST HOSPITAL 91 18.9 51 11.7 0 0.0 1 2.1
Orange ANAHEIM GENERAL HOSPITAL 159 31.0 69 15.7 1 1.1 1 1.0
Orange ANAHEIM MEMORIAL MEDICAL CENTER 418 24.3 200 13.5 6 2.7 9 3.6
Orange CHAPMAN MEDICAL CENTER . . . . . . . .
Orange CHILDREN’S HOSPITAL AT MISSION . . . . . . . .
Orange CHILDREN’S HOSPITAL OF ORANGE COUNTY . . . . . . . .
Orange COASTAL COMMUNITIES HOSPITAL 876 41.9 438 25.8 1 0.2 1 0.2
Orange COLLEGE HOSPITAL COSTA MESA . . . . . . . .
Orange FOUNTAIN VALLEY RGNL HOSP AND MED CTR – EUCLID 896 25.2 506 16.6 34 8.1 36 7.4
Orange GARDEN GROVE HOSPITAL AND MEDICAL CENTER 855 32.8 379 17.5 19 3.8 21 3.7
Orange HOAG MEMORIAL HOSPITAL PRESBYTERIAN 1595 30.2 896 21.0 26 3.7 27 3.4
Orange HUNTINGTON BEACH HOSPITAL . . . . . . . .
Orange IRVINE REGIONAL HOSPITAL AND MEDICAL CENTER 554 29.3 278 18.5 19 6.5 19 6.2
Orange KAISER FND HOSP – ANAHEIM 709 22.1 378 14.0 93 22.1 102 21.1
Orange KINDRED HOSPITAL BREA . . . . . . . .
Orange KINDRED HOSPITAL WESTMINSTER . . . . . . . .
Orange LA PALMA INTERCOMMUNITY HOSPITAL 67 22.3 33 12.3 0 0.0 0 0.0
Orange LOS ALAMITOS MEDICAL CENTER 456 25.9 192 13.0 5 1.9 7 2.4
Orange MISSION HOSPITAL REGIONAL MEDICAL CENTER 793 28.1 421 17.7 18 4.7 23 5.2
Orange ORANGE COAST MEMORIAL MEDICAL CENTER 379 25.6 176 14.4 7 3.4 9 4.0
Orange PLACENTIA LINDA HOSPITAL . . . . . . . .
Orange SADDLEBACK MEMORIAL MEDICAL CENTER 626 23.9 299 14.3 60 15.9 67 15.3
Orange SADDLEBACK MEMORIAL MEDICAL CENTER – SAN CLEMENTE . . . . . . . .
Orange SOUTH COAST MEDICAL CENTER 189 28.4 101 18.6 10 10.3 10 9.8
Orange ST. JOSEPH HOSPITAL – ORANGE 1469 32.2 735 19.7 54 6.9 60 6.8
Orange ST. JUDE MEDICAL CENTER 523 26.3 295 17.8 30 11.8 32 11.1
Orange TUSTIN HOSPITAL MEDICAL CENTER . . . . . . . .
Orange UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER 255 26.1 132 15.7 34 21.6 43 19.3
Orange WESTERN MEDICAL CENTER – SANTA ANA 992 34.4 437 18.4 11 1.9 12 1.8
Orange WESTERN MEDICAL CENTER HOSPITAL – ANAHEIM 721 28.4 240 11.2 3 0.6 5 1.0
Placer KAISER FND HOSP – SACRAMENTO/ROSEVILLE-EUREKA . . . . . . . .
Placer SUTTER AUBURN FAITH HOSPITAL 121 26.2 62 14.9 0 0.0 0 0.0
Placer SUTTER ROSEVILLE MEDICAL CENTER 655 24.1 295 12.9 41 10.2 42 9.8
Plumas EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS . . . . . . . .
Plumas PLUMAS DISTRICT HOSPITAL 22 24.3 11 13.6 0 0.0 0 0.0
Plumas SENECA HEALTHCARE DISTRICT . . . . . . . .
Riverside CORONA REGIONAL MEDICAL CENTER-MAIN 527 28.7 265 16.4 3 1.1 3 1.0
Riverside DESERT REGIONAL MEDICAL CENTER 1027 33.2 500 19.2 25 4.5 28 4.5
Riverside EISENHOWER MEMORIAL HOSPITAL 0 0.0 0 0.0 0 0.0 0 0.0
Riverside HEMET VALLEY MEDICAL CENTER 578 44.6 361 31.4 1 0.5 1 0.4
Riverside JOHN F KENNEDY MEMORIAL HOSPITAL 953 34.3 427 17.9 4 0.7 5 0.8
Riverside KAISER FND HOSP – RIVERSIDE 909 25.8 488 16.2 79 15.7 87 15.7
Riverside MENIFEE VALLEY MEDICAL CENTER . . . . . . . .
Riverside MORENO VALLEY COMMUNITY HOSPITAL 372 25.9 139 11.0 0 0.0 0 0.0
Riverside PALO VERDE HOSPITAL 41 41.8 30 32.6 1 8.2 1 5.8
Riverside PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER 603 36.8 274 20.2 4 1.2 5 1.3
Riverside RIVERSIDE COMMUNITY HOSPITAL 948 32.0 492 19.0 1 0.2 1 0.2
Riverside RIVERSIDE COUNTY REGIONAL MEDICAL CENTER 674 25.4 226 9.9 36 7.3 41 7.3
Riverside SAN GORGONIO MEMORIAL HOSPITAL 128 33.1 52 15.5 0 0.0 0 0.0
Riverside SOUTHWEST HEALTHCARE SYSTEM-MURRIETA 854 25.6 394 13.7 13 2.7 14 2.7
Riverside VISTA HOSPITAL OF RIVERSIDE . . . . . . . .
Sacramento KAISER FND HOSP – SACRAMENTO/ROSEVILLE-MORSE 868 24.5 474 15.7 89 18.5 101 17.8
Sacramento KAISER FND HOSP – SOUTH SACRAMENTO 532 15.8 270 9.2 116 30.8 133 31.7
Sacramento KINDRED HOSPITAL – SACRAMENTO . . . . . . . .
Sacramento MERCY GENERAL HOSPITAL 644 28.3 354 17.4 35 10.6 38 10.3
Sacramento MERCY HOSPITAL – FOLSOM 257 23.1 105 11.7 10 6.3 10 6.0
Sacramento MERCY SAN JUAN HOSPITAL 674 25.1 360 15.0 52 14.1 58 13.1
Sacramento METHODIST HOSPITAL OF SACRAMENTO 266 24.6 144 15.3 21 14.7 22 12.8
Sacramento SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF. . . . . . . . .
Sacramento SUTTER GENERAL HOSPITAL . . . . . . . .
Sacramento SUTTER MEMORIAL HOSPITAL 1305 27.2 640 15.8 111 14.3 123 13.4
Sacramento UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER 539 25.1 307 16.6 88 27.4 96 25.5
San Benito HAZEL HAWKINS MEMORIAL HOSPITAL 166 33.0 80 18.2 1 1.1 2 2.1
San Bernardino ARROWHEAD REGIONAL MEDICAL CENTER 965 28.9 415 14.3 51 8.4 54 7.9
San Bernardino BARSTOW COMMUNITY HOSPITAL 88 31.1 37 14.7 3 5.4 4 6.8
San Bernardino BEAR VALLEY COMMUNITY HOSPITAL . . . . . . . .
San Bernardino CHINO VALLEY MEDICAL CENTER 0 0.0 0 0.0 0 0.0 0 0.0
San Bernardino COLORADO RIVER MEDICAL CENTER . . . . . . . .
San Bernardino COMMUNITY HOSPITAL OF SAN BERNARDINO 1109 45.2 584 28.6 3 0.6 5 0.8
San Bernardino DESERT VALLEY HOSPITAL 116 32.3 46 15.3 1 1.4 1 1.3
San Bernardino HI-DESERT MEDICAL CENTER 151 36.7 89 23.6 1 1.6 1 1.4
San Bernardino KAISER FND HOSP – FONTANA 942 22.9 440 12.4 82 14.0 90 13.5
San Bernardino KINDRED HOSPITAL ONTARIO 0 0.0 0 0.0 0 0.0 0 0.0
San Bernardino LOMA LINDA UNIVERSITY MEDICAL CENTER 595 28.2 289 16.2 61 16.4 75 15.8
San Bernardino MONTCLAIR HOSPITAL MEDICAL CENTER 335 40.6 196 27.2 1 0.7 1 0.6
San Bernardino MOUNTAINS COMMUNITY HOSPITAL 32 28.0 17 16.4 0 0.0 0 0.0
San Bernardino RANCHO SPECIALTY HOSPITAL . . . . . . . .
San Bernardino REDLANDS COMMUNITY HOSPITAL 538 25.7 285 15.3 1 0.4 4 1.4
San Bernardino SAN ANTONIO COMMUNITY HOSPITAL 756 36.2 431 25.3 2 0.6 2 0.5
San Bernardino ST. BERNARDINE MEDICAL CENTER 363 21.8 165 10.8 14 6.5 15 5.9
San Bernardino ST. MARY REGIONAL MEDICAL CENTER 459 19.6 198 9.1 7 2.6 7 2.2
San Bernardino VICTOR VALLEY COMMUNITY HOSPITAL 479 33.9 160 13.9 3 0.9 4 1.1
San Diego ALVARADO HOSPITAL . . . . . . . .
San Diego FALLBROOK HOSPITAL DISTRICT 147 33.8 79 21.7 6 8.1 6 7.2
San Diego GROSSMONT HOSPITAL 965 30.6 530 19.7 77 15.0 83 14.3
San Diego KAISER FND HOSP – SAN DIEGO 1061 26.8 621 18.4 81 15.6 90 15.2
San Diego KINDRED HOSPITAL – SAN DIEGO . . . . . . . .
San Diego PALOMAR MEDICAL CENTER 1104 29.4 531 16.9 88 13.2 90 12.6
San Diego PARADISE VALLEY HOSPITAL 357 25.6 163 13.7 1 0.5 2 0.9
San Diego POMERADO HOSPITAL 326 30.7 152 17.7 1 0.6 1 0.5
San Diego PROMISE HOSPITAL OF SAN DIEGO . . . . . . . .
San Diego RADY CHILDREN’S HOSPITAL – SAN DIEGO . . . . . . . .
San Diego SAN DIEGO HOSPICE AND PALLIATIVE CARE-ACUTE CARE CTR . . . . . . . .
San Diego SCRIPPS GREEN HOSPITAL . . . . . . . .
San Diego SCRIPPS MEMORIAL HOSPITAL – ENCINITAS 330 21.7 152 12.0 41 18.8 44 19.0
San Diego SCRIPPS MEMORIAL HOSPITAL – LA JOLLA 1255 30.7 715 22.2 66 11.2 69 10.6
San Diego SCRIPPS MERCY HOSPITAL 517 24.2 300 16.0 77 26.2 83 25.6
San Diego SCRIPPS MERCY HOSPITAL – CHULA VISTA 629 35.3 393 24.4 11 4.4 12 4.4
San Diego SHARP CHULA VISTA MEDICAL CENTER 1021 33.8 405 16.7 7 1.1 7 1.0
San Diego SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER . . . . . . . .
San Diego SHARP MARY BIRCH HOSPITAL FOR WOMEN 2469 33.4 1338 22.2 104 8.4 122 8.4
San Diego SHARP MEMORIAL HOSPITAL . . . . . . . .
San Diego TRI-CITY MEDICAL CENTER 933 28.1 523 18.0 60 12.6 67 12.2
San Diego UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER 712 30.5 447 22.1 35 11.8 45 12.0
San Francisco CALIFORNIA PACIFIC MED CTR-PACIFIC CAMPUS 1197 19.5 711 13.6 64 12.2 74 11.7
San Francisco CHINESE HOSPITAL . . . . . . . .
San Francisco KAISER FND HOSP – GEARY S F 638 25.0 401 18.7 47 17.0 53 16.9
San Francisco LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER . . . . . . . .
San Francisco SAN FRANCISCO GENERAL HOSPITAL 202 18.3 110 11.1 47 33.6 53 33.0
San Francisco ST. FRANCIS MEMORIAL HOSPITAL . . . . . . . .
San Francisco ST. LUKE’S HOSPITAL 195 18.7 108 11.4 9 9.3 9 8.1
San Francisco ST. MARY’S MEDICAL CENTER, SAN FRANCISCO . . . . . . . .
San Francisco UCSF MEDICAL CENTER 335 19.2 216 14.2 48 29.5 53 25.8
San Joaquin DAMERON HOSPITAL 575 27.2 300 16.2 12 4.2 20 5.5
San Joaquin DOCTORS HOSPITAL OF MANTECA 164 24.7 65 11.1 0 0.0 2 1.8
San Joaquin KAISER FND HOSP-MANTECA . . . . . . . .
San Joaquin LODI MEMORIAL HOSPITAL 414 36.9 220 22.9 0 0.0 1 0.5
San Joaquin SAN JOAQUIN GENERAL HOSPITAL 630 28.1 241 12.5 18 4.4 22 4.8
San Joaquin ST. JOSEPH’S MEDICAL CENTER OF STOCKTON 583 27.9 276 14.9 11 3.4 11 3.0
San Joaquin SUTTER TRACY COMMUNITY HOSPITAL 204 29.2 97 16.5 1 0.9 1 0.8
San Luis Obispo ARROYO GRANDE COMMUNITY HOSPITAL . . . . . . . .
San Luis Obispo FRENCH HOSPITAL MEDICAL CENTER 158 20.2 99 13.6 1 1.7 1 1.5
San Luis Obispo SIERRA VISTA REGIONAL MEDICAL CENTER 346 31.1 161 18.6 38 17.2 40 16.0
San Luis Obispo TWIN CITIES COMMUNITY HOSPITAL 154 25.8 79 14.7 4 5.0 5 5.3
San Mateo KAISER FND HOSP – REDWOOD CITY 197 14.6 114 9.6 40 32.9 42 32.1
San Mateo KAISER FND HOSP – SOUTH SAN FRANCISCO . . . . . . . .
San Mateo MENLO PARK SURGICAL HOSPITAL . . . . . . . .
San Mateo PENINSULA MEDICAL CENTER 398 21.3 221 13.9 12 6.5 13 5.5
San Mateo SAN MATEO MEDICAL CENTER . . . . . . . .
San Mateo SEQUOIA HOSPITAL 365 25.8 190 17.1 24 12.6 24 11.2
San Mateo SETON MEDICAL CENTER 144 22.8 100 17.4 19 30.0 20 28.8
Santa Barbara GOLETA VALLEY COTTAGE HOSPITAL 66 23.0 31 12.5 0 0.0 0 0.0
Santa Barbara LOMPOC HEALTHCARE DISTRICT 105 27.0 57 16.0 0 0.0 1 1.9
Santa Barbara MARIAN MEDICAL CENTER 885 34.3 370 17.2 4 0.8 6 1.0
Santa Barbara SANTA BARBARA COTTAGE HOSPITAL 580 26.5 269 14.5 3 1.0 4 1.1
Santa Barbara SANTA YNEZ VALLEY COTTAGE HOSPITAL . . . . . . . .
Santa Clara COMMUNITY HOSPITAL OF LOS GATOS 189 24.4 97 15.5 14 13.4 14 12.8
Santa Clara EL CAMINO HOSPITAL 1167 26.2 649 17.6 10 1.9 10 1.7
Santa Clara GOOD SAMARITAN HOSPITAL-SAN JOSE 1065 30.7 634 22.4 17 3.9 22 4.4
Santa Clara KAISER FND HOSP – SAN JOSE 484 20.4 268 13.1 59 21.5 64 21.4
Santa Clara KAISER FND HOSP – SANTA CLARA 432 21.5 275 15.9 58 27.1 64 25.8
Santa Clara KAISER FND HOSP – SANTA CLARA 432 21.5 275 15.9 58 27.1 64 25.8
Santa Clara LUCILE SALTER PACKARD CHILDREN’S HOSP. AT STANFORD 983 20.6 488 12.1 108 18.3 116 15.8
Santa Clara O’CONNOR HOSPITAL – SAN JOSE 983 27.7 500 16.7 11 2.2 11 2.0
Santa Clara REGIONAL MEDICAL OF SAN JOSE 189 28.3 87 15.9 3 2.9 4 3.4
Santa Clara SANTA CLARA VALLEY MEDICAL CENTER 945 20.0 418 10.2 265 33.2 289 31.3
Santa Clara ST. LOUISE REGIONAL HOSPITAL 122 26.0 59 14.0 1 1.6 2 2.8
Santa Clara STANFORD HOSPITAL 4 89.1 4 85.9 0 0.0 0 0.0
Santa Cruz DOMINICAN HOSPITAL-SANTA CRUZ/SOQUEL 232 22.5 101 12.0 39 23.0 42 21.0
Santa Cruz SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ 183 19.6 112 13.7 20 22.4 20 20.6
Santa Cruz WATSONVILLE COMMUNITY HOSPITAL 388 27.6 172 14.2 16 6.9 19 7.2
Shasta MAYERS MEMORIAL HOSPITAL 22 22.7 10 11.3 0 0.0 0 0.0
Shasta MERCY MEDICAL CENTER 472 27.1 220 14.2 2 0.8 2 0.7
Shasta NORTHERN CALIFORNIA REHABILITATION HOSPITAL . . . . . . . .
Shasta PATIENTS’ HOSPITAL OF REDDING . . . . . . . .
Shasta SHASTA REGIONAL MEDICAL CENTER . . . . . . . .
Siskiyou FAIRCHILD MEDICAL CENTER 77 39.2 47 27.2 2 6.2 2 5.5
Siskiyou MERCY MEDICAL CENTER MT. SHASTA 39 26.6 19 14.4 1 4.7 1 4.3
Solano KAISER FND HOSP – REHABILITATION CENTER VALLEJO 567 25.0 309 15.8 45 14.8 49 15.0
Solano NORTH BAY MEDICAL CENTER 370 27.7 174 14.7 2 1.0 3 1.3
Solano NORTH BAY VACAVALLEY HOSPITAL . . . . . . . .
Solano SUTTER SOLANO MEDICAL CENTER 228 26.1 115 15.1 23 16.8 25 16.1
Sonoma HEALDSBURG DISTRICT HOSPITAL . . . . . . . .
Sonoma KAISER FND HOSP – SANTA ROSA 381 22.0 203 13.7 32 15.3 39 16.8
Sonoma PALM DRIVE HOSPITAL . . . . . . . .
Sonoma PETALUMA VALLEY HOSPITAL 124 24.1 62 13.5 1 1.6 1 1.4
Sonoma SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY 279 24.7 110 12.2 43 20.2 48 20.3
Sonoma SONOMA VALLEY HOSPITAL 43 22.8 19 11.3 0 0.0 0 0.0
Sonoma SUTTER MEDICAL CENTER OF SANTA ROSA-CHANATE CAMPUS 273 17.8 144 10.0 0 0.0 1 0.7
Stanislaus DOCTORS MEDICAL CENTER 1308 33.3 585 17.6 50 6.4 50 5.8
Stanislaus EMANUEL MEDICAL CENTER, INC 558 21.0 223 9.6 16 4.5 16 4.4
Stanislaus MEMORIAL HOSPITAL MEDICAL CENTER – MODESTO 551 29.2 285 17.3 1 0.4 3 1.0
Stanislaus OAK VALLEY DISTRICT HOSPITAL (2-RH) 70 26.2 33 13.7 0 0.0 1 2.6
Stanislaus STANISLAUS SURGICAL HOSPITAL . . . . . . . .
Sutter FREMONT MEDICAL CENTER 515 27.0 217 13.1 30 9.0 35 9.5
Tehama ST. ELIZABETH COMMUNITY HOSPITAL 152 25.4 76 13.8 0 0.0 0 0.0
Trinity TRINITY HOSPITAL . . . . . . . .
Tulare KAWEAH DELTA DISTRICT HOSPITAL 1175 34.3 559 19.3 22 3.4 25 3.3
Tulare SIERRA VIEW DISTRICT HOSPITAL 546 29.8 285 17.2 1 0.4 1 0.4
Tulare TULARE DISTRICT HOSPITAL 419 40.8 202 23.3 1 0.5 1 0.4
Tuolumne SONORA REGIONAL MEDICAL CENTER – GREENLEY 158 32.9 79 19.1 0 0.0 0 0.0
Tuolumne TUOLUMNE GENERAL MEDICAL FACILITY . . . . . . . .
Ventura COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA 820 30.4 363 16.3 8 1.7 8 1.5
Ventura LOS ROBLES HOSPITAL & MEDICAL CENTER