Category Archives: VBAC Bans

“No one can force you to have a cesarean” is false

Update: Since this article was originally published, it has been updated with several new resources (listed at the bottom) as well as a video.

 

hospital-bed

 

“No one can force you to have a cesarean.” I see this all the time in message boards.

Don’t worry about

… the VBAC ban

…your unsupportive provider

… your provider’s 40 week deadline

… [insert other VBAC barrier here]

no one can force you to have a cesarean.

That’s just not true.

Let’s start with what is ethical and legal: Yes, no one can legally force you to have a cesarean.

ACOG even says in their latest VBAC guidelines that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” So even if your facility has a VBAC ban, they still cannot force you to have surgery… legally or ethically.

But then you have reality: It happens all the time, but it may look different than you expect.

It’s often NOT a woman screaming “I do not consent” as she is wheeled into the OR, though that has happened.

It’s through lies. It’s through fear.

“The risk of uterine rupture is 25%.”

“Do you want a healthy baby or a birth experience?”

“Planning a VBAC is like running across a busy freeway.”

Hospital policy and provider preference are presented as superseding the woman’s right to decline surgery.

“No one attends VBAC here.”

“It’s against our policy.”

“We don’t allow VBACs.”

Or unreasonable timelines are assigned giving the woman the illusion of choice.

“You have to go into labor by 39 weeks.”

“Your labor can’t be longer than 12 hours.”

“You have to dilate at least 1 centimeter per hour.”

Or it can be a slow process where a seemingly once supportive provider quietly withdraws support exchanging words of encouragement with caution. Dr. Brad Bootstaylor, an Atlanta based OBGYN, describes how this can unfold at 4:00 in this video after a woman describes her experience:

Or, if the birthing parents don’t listen, it can escalate to calling social services, ordering a psychiatric evaluation, or even getting a court order for a forced cesarean.

It can be as simple as, “Your baby is distress.” How do you know if this is true or not? Are you willing to take that risk?

Some people suggest that parents should learn how to interpret fetal heart tones so they can evaluate their baby’s status. But I think this is a wholly unreasonable expectation for non-medical professionals, especially when one is in labor. It is as much an art as it is a science.

In short, coercion frequently isn’t by physical force. It’s through manipulation. This is why it’s worth your time and effort to search for a supportive provider who you trust to attend your birth.

Don’t just think, “Well, I can hire anyone and simply refuse.”

Sometimes it’s not that simple as Rinat Dray, was forced to have a cesarean, and Kimberly Turbin, who received a 12-cut episiotomy while yelling “Do not cut me,” know all too well.

And this is why understanding the complete picture is important. It’s not enough to ponder how things are “supposed to be” or how we want them to be, but how they actually are. The difference between perception and reality is huge. Learn more in my online workshop, “The Truth About VBAC.”

Have you seen a situation like described above play out? Share it in the comment section.

Continue the conversation & share on Facebook here:

There is a huge difference between what is legal, what is ethical, and what actually happens. #forcedcesareans #ethicalvsreality #vbacfacts

Posted by www.VBACFACTS.com on Wednesday, January 6, 2016

 

Learn more:

ACLU. (n.d.). Coercive and punitive governmental responses womens conduct during pregnancy. Retrieved from ACLU: https://www.aclu.org/coercive-and-punitive-governmental-responses-womens-conduct-during-pregnancy

Cantor, J. D. (2012, Jun 14). Court-Ordered Care — A Complication of Pregnancy to Avoid. New England Journal of Medicine, 366, 2237-2240. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1203742?

Hartocollis, A. (2014, May 16). Mother accuses doctors of forcing a c-section and files suit. Retrieved from The New York Times: http://nytimes.com/2014/05/17/nyregion/mother-accuses-doctors-of-forcing-a-c-section-and-files-suit.html?referrer=&_r=0

Human Rights in Childbirth. (2015, Jan 14). Rinat Dray is not alone, Part 1. Retrieved from Human Rights in Childbirth: http://www.humanrightsinchildbirth.org/amicusbriefpart1/

International Cesarean Awareness Network. (n.d.). Your right to refuse: What to do if your hospital has “banned” VBAC. Retrieved from Feminist Women’s Health Center: http://www.fwhc.org/health/pdf_about_vbac.pdf

Jacobson, J. (2014, Jul 25). Florida hospital demands woman undergo forced c-section. Retrieved from RH Reality Check: http://rhrealitycheck.org/article/2014/07/25/florida-hospital-demands-woman-undergo-forced-c-section/

Kamel, J. (2012, Mar 2). Options for a mom who will be ‘forced’ to have a cesarean. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/02/options-mom-forced-repeat-cs/

Maryland Families for Safe Birth. (2015, Jan 28). The truth about VBAC: Maryland families need access. Retrieved from YouTube: https://youtu.be/C5nymk3IGqE

Paltrow, L. M., & Flavin, J. (2013, April). Arrests of and forced interventions on pregnant women in the United States, 1973-2005: Implications for women’s legal status and public health. Journal of Health Politics, Policy and Law, 38(2), 299-343. Retrieved from http://jhppl.dukejournals.org/content/early/2013/01/15/03616878-1966324.full.pdf+html

Pascucci, C. (2015, Jun 4). Press Release: Woman charges OB with assault & battery for forced episiotomy. Retrieved from Improving Birth: http://improvingbirth.org/2015/06/preview-woman-charges-ob-with-assault-battery-for-forced-episiotomy/

What I told the California Medical Board about home VBAC

california state seal

A little backstory

Back in October, I attended my first Interested Parties Meeting held by the Medical Board of California regarding new midwifery regulations as required by AB1308. (Read more about AB1308 here and here.)  Up for discussion was which conditions or histories among women seeking a home birth with a Licensed Midwife should be required to obtain physician approval.  A prior cesarean was on the list of over 60 conditions or histories and home VBAC was the one subject that generated the most comment and discussion that day.

What does AB1308 mean in terms of home VBAC in California?

There has been a lot of confusion regarding what AB1308 means in terms of home VBAC in California. In an effort to clear things up, Constance Rock-Stillman, LM, CPM, President, California Association of Midwives said this on January 23, 2014:

AB 1308 went into effect on 1/1/14, but there is nothing in the new legislation that says we [CPM/LMs] cannot do VBACs. We can do VBACs. We just need to define in our regulations what preexisting conditions will require physician consultation. [Which is what the October 15 and December 15th Interested Party meetings were about.] Until the new regulations are written we should continue to follow our current regulations and they only require us to provide certain disclosures and informed consent to clients.

Please let the community know that if they want to have a say in whether or not VBACs with Ca LMs require a physician consultation, they should come to the Interested Parties meeting that the medical board will be holding and tell the board how they feel about it. The medical board is a consumer protection agency, so they need to hear what consumers want to be protected from.

We will let you know as soon as the meeting is scheduled.

[Ms. Rock-Stillman responds when questioned by those who have not been involved it the creation of this legislation yet insist this legislation removes the option of home VBAC entirely:]

I’m in my third year as president of the California Association of Midwives, and I’m a practicing licensed midwife. I have been at every Midwifery Advisory Counsel meeting, at the Capitol 30 times last year, I’ve spoken in legislative committee hearings, I’ve sat in weekly meetings with CAM’s legal counsel who worked side-by-side with us on the legislation, I’ve been in Assemblywoman Susan Bonilla’s boardroom with ACOG and at every one of the public events where Susan Bonilla promised that the LMs would still be able to do VBACs. So I think I qualify as a knowledgeable stakeholder in this issue. Yes, we intentionally left VBAC out of the list of prohibited conditions, so at this point there is no question as to whether or not we can do VBACs. The only part that’s in question is whether or not all VBACs will require physician consultation. Regulations that clarify under what circumstances physician consultation will be required will be written by the California Medical Board.  This is a process that takes time. Maybe even a year or more. The regulations that will be adopted will be based on evidence and input from all the stakeholders. This is why I think it’s so important that midwives and consumers be at the meetings to insure their voices get heard. At the last Interested Parties meeting that the medical board held, I asked what we were suppose to do until the new regulations are written and we were told that we should follow our current regulations and our community standards until new regulations are adopted.

Why I attended

VBAC-relic

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My intention in attending the October 15, 2014 meeting was to amplify the voice of the consumer.  I think sometimes it’s difficult for OBs who attend VBACs, or for those who live in communities where they have access to hospitals that allow VBAC, to understand that not everyone lives in that world.

Some live in a world where if they want a VBAC in a hospital with a supportive midwife or doctor who takes their insurance, that means driving over 50 miles each way for prenatal care and delivery while they literally drive by other facilities that offer labor and delivery, but ban VBAC.  Or it means acquiescing to a unnecessary repeat cesarean whose risks compound with every surgery. Or it means planning an unassisted birth which comes with its own set of risks. This is a tremendous burden.

As VBAC and repeat cesarean both carry risks and benefits, and women are the ones who bear and endure those risks, they should be the ones who choose which mode of delivery is acceptable to them. I celebrate when women have access to supportive hospital-based practitioners.  But the reality is, many women do not enjoy that privilege and yet they still wish to avoid the serious complications that come with each cesarean surgery.

Who else was at the meeting?

Other people in the room included the Senior Staff Counsel of the Medical Board, an OB-GYN representing ACOG, an ACOG lobbyist, Constance Rock-Stillman along with many other CAM representatives and midwives, California Families for Access to Midwives, a few other consumers, and me. Senior Staff Counsel was tasked with writing these regulations and as the meeting progressed, items were reworded or removed from the list.

Below is the five minute presentation I prepared and presented to the Medical Board on October 15, 2014.  As there was a limited time to speak, I sent a follow-up letter to the Medical Board which goes into more depth. I’ll be posting that soon.

My statement

Today I’m speaking on behalf of consumers regarding the importance of out of hospital VBAC. I will be focusing on the impact of requiring women seeking out of hospital VBAC to obtain physician approval. This proves problematic because very few physicians, if any, would be willing to sign off on a home VBAC due to liability concerns. This would effectively cut off the option of a vaginal delivery for many women throughout our state.

I’m Jennifer Kamel, Founder of VBAC Facts, an organization which seeks to close the gap between what best practice guidelines and the evidence says about VBAC vs. repeat cesarean and what people generally believe.

Some people may think reducing access to out of hospital VBAC is not a big deal. But 44% of California hospitals ban VBAC (Barger, 2013) despite the American College of OBGYNs (2010) and the National Institutes of Health’s (2010) assertion that VBAC is a safe, reasonable, and appropriate option for most women.

ACOG (2010) is clear, “Respect for patient autonomy argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.” But this recommendation is simply ignored by many facilities.

Consumers report that many facilities provide incomplete or misleading informed consent, maintain a strict VBAC ban, and ignore ACOG’s comments denouncing forced cesareans.  These facilities led women to believe that a repeat cesarean is their only option.

As a Sacramento area OB-GYN resident recently shared, “There is the routine overplaying of the risks of VBAC, and failure to mention the risks of repeat cesareans, or that ACOG considers VBAC safe and reasonable.”

With the cloud of legal liability hanging over our heads, I wonder about the culpability of the many facilities whose hospital policies mandate repeat cesareans and forbid VBACs yet who are also unprepared to manage the serious consequences of multiple repeat cesarean sections including placenta accreta, cesarean hysterectomies, and hemorrhage. (Heller, 2013)

VBAC is successful about 75% of the time, most women are candidates (ACOG, 2010), about half of women are interested in the option (Declercq E. R., Sakala, Corry, Applebaum, & Herrlick, 2013), and VBAC results in lower maternal morbidity and mortality rates in the current delivery as well as in future deliveries. Yet, VBAC is simply not occurring in many communities throughout the state of California resulting in a 9% VBAC rate statewide. (State of California Office of Statewide Health Planning and Development, 2013)

According to Barger (2013), a study looking at the prevalence of VBAC bans in California, “Among the 56% [of hospitals that offer trial of labor after cesarean or TOLAC], the median VBAC rate was 10.8% (range 0-37.3%)…According to the nurses surveyed, we found that about half of hospitals with continuous anesthesia coverage did not offer TOLAC, not because of an explicit hospital policy against it, but because physicians were unwilling to stay in the hospital with a woman attempting TOLAC.”  So even in facilities that offered VBAC, attaining one and avoiding surgery can be elusive.

It is within this climate that women choose out-of-hospital VBAC. For many women in the state, VBAC is simply not a viable option at their local facility. Barger (2013) found that “The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. [as the crow flies] with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital. In 2012, 139 hospitals offered TOLAC, [which was] 16.6% fewer than in 2007.” So the trend is moving towards fewer hospitals offering VBAC.

For some women traveling to a hospital that offers VBAC and accepts their insurance is a huge burden consisting of coordinating work and school schedules, vacation and sick time, and the cost of travel and child care. We do not want to be in a position where state troopers are attending births on the side of the road.

As Dr. Elliott Main (2013), Medical Director of the California Maternal Quality Care Collaborative (CMQCC), has stressed, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean.”

Women should not feel like home VBAC is their only option, but for too many women their choice is limited to home VBAC or repeat cesarean. If a hospital VBAC is not a possibility and the choice of out-of-hospital birth is removed, that essentially forces women into either unwanted and unneeded repeat cesarean surgery, and the increasing risks that come with multiple prior cesareans, or into unassisted home births where they deliver without an midwife or doctor.

In light of the recommendations made by ACOG and the NIH and the realities of increasing maternal morbidity rates in the state of California due to multiple repeat cesarean sections, the objective should be making VBAC more accessible, not less.

Bibliography

American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116(2), 450-463.

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197.

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

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

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

Why cesareans are a big deal to you, your wife, and your daughter

surgery-surgical-instrumentsI hear a lot, “What’s the big deal about cesareans? What difference does it really make if you have a cesarean?” Of course, if a cesarean is medically necessary, then the benefits outweigh the risks. But in the absence of a medical reason, the risks of cesareans must be carefully considered.

“Once a cesarean, always a cesarean”

If a woman has a cesarean, she is very likely to only have cesareans for future births. This is because while 45% of American women are interested in the option of VBAC (1), 92% have a repeat cesarean (2). Let me say that another way. Only 8% of women with a prior cesarean successfully VBAC.

One might interpret this statistic to mean that planned VBACs often end in a repeat cesarean. However, VBACs are successful about 75% of the time (3-7). The VBAC rate is so low because of the women interested in VBAC, 57% are unable to find a supportive care provider or hospital (1). And I would argue further that even among the women who have a supportive care provider, those women are so bombarded by fear based misinformation masquerading as caring advice from friends and family, they have no chance.  It is shocking to learn how ill-informed both women planning VBACs and repeat cesareans are about their birth options even upon admission to the hospital.  There is a fundamental gap in our collective wisdom about post-cesarean birth options.

Cesareans make subsequent pregnancies riskier

What’s the big deal, right? Who cares if you have a cesarean without a medical reason?

Forget about the immediate risks to mom and baby that cesareans impose. Just set that all aside for a moment.  Much of the risk associated with cesareans is delayed.  Most people are not aware of the long term issues that can come with cesareans and how these complications impact the safety of future pregnancies, deliveries, and children.

It is a well-established fact that the more cesareans a woman has, the more risky subsequent pregnancies and labors are regardless if the mom plans a VBAC or a repeat cesarean.  This was discussed at great lengths during the 2010 National Institutes of Health VBAC conference and was one of the reasons why ACOG released their less restrictive VBAC guidelines later that same year.

Many moms chose repeat cesareans because they believe cesareans are the prudent, safest choice. The fact that cesareans, of which over 1,000,000 occur in the USA each year, increases the complication rates of future pregnancies is often not disclosed to women during their VBAC consult.

A four year study looking at up to six cesareans in 30,000 women reported a startling number of complications that increased at a statistically significant rate as the prior number of cesareans increased:

The risks of placenta accreta [which has a maternal mortality of 7% and hysterectomy risk of 71%], cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral injury [damage to the ureters – the tubes that connect the kidneys to the bladder in which urine flows – is one of the most serious complications of gynecologic surgery], and ileus [disruption of the normal propulsive gastrointestinal motor activity which can lead to bowel (intestinal) obstructions], the need for postoperative ventilation [this means mom can’t breathe on her own after the surgery], intensive care unit admission [mom is having major complications], hysterectomy, and blood transfusion requiring 4 or more units [mom hemorrhaged], and the duration of operative time [primarily due to adhesions] and hospital stay significantly increased with increasing number of cesarean deliveries (8).

Because the growing likelihood of serious complications that comes with each subsequent cesarean surgery, including uterine rupture, this study concluded,

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 (8).

This is because the risks of placenta accreta and previa in particular increase at a very high rate after multiple cesareans (9).

The largest prospective report of uterine rupture in women without a previous cesarean in a Western country,” concurred:

Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture (10).

“Well, I just plan on having two kids…”

Unfortunately, many women don’t think about these future risks until they are pregnant again. And we all know the great difference between intended and actual family size.

According to the CDC, 49% of American pregnancies are unintentional (11). Thus, these theoretical risks quickly and suddenly become a reality for hundreds of thousands of American women every year. How women birth their current baby has real and well-documented implications and risks for their future pregnancies, children, and health.

VBAC bans and emergency response

In light of these increasing risks, VBAC bans do not make moms safer (12). Hospitals are either prepared for obstetrical complications, like uterine rupture in moms who plan VBACs and placenta accreta, previa, and cesarean hysterectomies among moms who plan repeat cesareans, or they are not. It is hard to understand how hospitals can claim that they are simultaneously capable of an adequate response to cesarean-related complications and yet they are unable or ill-equipped to respond to complications related to vaginal birth after cesarean.  Especially in light of the fact that we know motivated hospitals currently offer VBAC even in the absence of 24/7 anesthesia (13).

A recent Wall Street Journal article discusses how hospitals are trying to create a standard response to obstetrical emergencies:

The CDC is funding programs in a number of states to establish guidelines and protocols for improving safety and preventing injury.  And obstetrics teams are holding drills to train doctors and nurses to rapidly respond to maternal complications. They are using simulated emergencies that include fake blood, robots that mimic physiologic states, and actresses standing in as patients (14).

Because hospitals vary so greatly in their ability to coordinate a expeditious response to urgent situations,

Vivian von Gruenigen, system medical director for women’s health services at Summa Health System in Akron, Ohio, advises that pregnant women discuss personal risks with their doctor and ask hospitals what kind of training delivery teams have to respond in an emergency. ‘People think pregnancy is benign in nature but that isn’t always the case, and women need to be their own advocates,’ Dr. von Gruenigen says.

Impact of VBAC on future births

Counter the increasing risks that come with cesareans to the downstream implications for VBAC. After the first successful VBAC, the future risk of uterine rupture, uterine dehiscence, and other labor related complications significantly decrease (15). Thus, family size must be considered as VBAC is often the safer choice for women planning large families.

Bottom line? I defer to two medical professionals and researchers:

“There is a major misperception that TOLAC [trial of labor after cesarean] is extremely risky” – Mona Lydon-Rochelle PhD, MPH, MS, CNM (16-17).

In terms of VBAC, “your risk is really, really quite low” – George Macones MD, MSCE (16-17).

Women deserve the facts

Women are entitled to accurate, honest data explained in a clear, easy to understand format (18). They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the facts or whose zealous desire for everyone to VBAC clouds their judgement (19-20).

If you would like to get the opinions of actual VBAC supportive medical professionals who support a woman’s right to informed consent, there are several obstetricians and midwives who you can talk to on the VBAC Facts Community.

Take home message

Cesareans are not benign and the more you have, the more risky your future pregnancies become regardless of your preferred mode of delivery.

Almost half of the pregnancies in America are unintentional.

If hospitals can attend to cesarean-related complications, they can attend to VBAC-related complications.

_________________________________________________

1. 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. Retrieved from Childbirth Connection: http://www.childbirthconnection.org/article.asp?ck=10068

2. Osterman, M. J., Martin, J. A., Mathews, T. J., & Hamilton, B. E. (2011, July 27). Expanded Data From the New Birth Certificate, 2008. Retrieved from CDC: National Vital Statistics Reports: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_07.pdf

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Kamel, J. (2012, Mar 30). Placenta problems in VBAMC/ after multiple repeat cesareans. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/

10. Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

11. National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

12. Kamel, J. (2012, Mar 27). Just kicking the can of risk down the road. Retrieved from VBAC Facts: http://vbacfacts.com/2012/03/27/just-kicking-the-can-of-risk-down-the-road/

13. Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/

14.  Landro, L. (2012, Dec 10). Steep Rise Of Complications In Childbirth Spurs Action. Retrieved from Wall Street Journal: http://online.wsj.com/article/SB10001424127887324339204578171531475181260.html?mod=rss_Health

15. Mercer BM, Gilbert S, Landon MB. et al. Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery. Obstet Gynecol. 2008 Feb;111(2):285-291. Retrieved from: http://journals.lww.com/greenjournal/Fulltext/2008/02000/Labor_Outcomes_With_Increasing_Number_of_Prior.6.aspx

16. NIH Consensus Development Conference. (2010). Vaginal Birth After Cesarean: New Insights. Bethesda, Maryland. Retrieved from http://consensus.nih.gov/2010/vbac.htm

17. Kamel, J. (2012, Apr 11). The best compilation of VBAC research to date. Retrieved from VBAC Facts: http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/

18. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: http://vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/

19. Kamel, J. (n.d.). Birth myths. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/birth-myths

20. Kamel, J. (n.d.). Scare tactics. Retrieved from VBAC Facts: http://vbacfacts.com/category/vbac/scare-tactics/

Thoughts on VBA3+C (VBAC after three or more prior cesareans)

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

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A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBA3+C (vaginal birth after three or more cesareans) candidate. (For a really great, though growing outdated, review of the VBAMC research click here.)

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Like women with one prior cesarean, I would suspect that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest success VBAMC (vaginal birth after multiple cesarean) rates.  In women with one prior cesarean, the average success rate is about 75%.  This increases to over 80% among women who had their cesarean for malpresentation and/or a history of a prior vaginal delivery.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC (we don’t have a lot of great data for VBA2C and even less so for VBA3+C), I think having low transverse incisions would be ideal.

kids-playing-on-see-saw

Here ACOG describes the qualities of a good VBAC candidate:

Good candidates for planned TOLAC are those women in whom the balance of risks (low as possible) and chances of success (as high as possible) are acceptable to the patient and health care provider. The balance of risks and benefits appropriate for one patient may seem unacceptable for another. Because delivery decisions made during the first pregnancy after a cesarean delivery will likely affect plans in future pregnancies, decisions regarding TOLAC should ideally consider the possibility of future pregnancies.

Although there is no universally agreed on discriminatory point, evidence suggests that women with at least a 60–70% chance of VBAC have equal or less maternal morbidity when they undergo TOLAC than women undergoing elective repeat cesarean delivery (62, 63).  Conversely, women who have a lower than 60% probability of VBAC have a greater chance of morbidity than woman undergoing repeat cesarean delivery. Similarly, because neonatal morbidity is higher in the setting of a failed TOLAC than in VBAC, women with higher chances of achieving VBAC have lower risks of neonatal morbidity.  One study demonstrated that composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for the women with the greatest probability of achieving VBAC (63).

The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.  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.  Individual circumstances must be considered in all cases, and if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC.

What does ACOG say about VBA2C?

In its latest VBAC recommendations, ACOG specifically addresses VBA2C:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision (64–68).  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC (66, 67).  One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries (67).  Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study) (67).

Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery.  Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

This hour long panel discussion followed the screening of More Business of Being Born: The VBAC Dilemma. On the panel are author/midwife Jenny West (The Complete Idiot’s Guide to Natural Childbirth and The Natural Healing Power of the Placenta), author/researcher Henci Goer (The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth), Nekole Shapiro of Embodied Birth, Stephanie Dawn of Sacred Birth and OB/GYN Dr. Craig Klose discussing the merits of vaginal birth after cesarean and various factors that may impede women being able to obtain VBACs.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were no biggie and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.  When conflicts arise between patient wishes and health care provider or facility policy or both, careful explanation and, if appropriate, transfer of care to facilities supporting TOLAC should be used rather than coercion.  Because relocation after the onset of labor is generally not appropriate in patients with a prior uterine scar, who are thereby at risk for uterine rupture, transfer of care to facilitate TOLAC, as noted previously, is best effected during the course of antenatal care.  This timing places a responsibility on patients and health care providers to begin relevant conversations early in the course of prenatal care.

Read a summary of ACOG’s VBAC recommendations and the actual original document.  You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Accreta, previa, hysterectomies, and cesareans

It has been well documented that the risks of placental abnormalities such as placenta accreta, placenta previa, and previa with accreta increase with each cesarean surgery and as a result, so does the rate of hysterectomy.  Silver (2006), a study of over 30,000 women and up to six cesareans quantified these risks per cesarean number.   You can read more about accreta, previa, previa with accreta and their associated complications.

Fang (2006) said, “abnormal adherent placentation [is] the primary indication leading to emergent peripartum [during the last month of pregnancy] hysterectomy… As the number of prior cesareans deliveries rises, the risk of cesarean hysterectomy increases dramatically.”

The Guise 2010 Evidence Report, which was the basis of the 2010 National Institutes of Health VBAC Conference, also discusses the risks of placental abnormalities by the number of prior cesareans.

So if you plan on having more children, a VBAMC (vaginal birth after multiple cesareans) would put a stop to the increasing rates of complications for future births as opposed to another cesarean which would just increase the risks in subsequent pregnancies.

Ultrasound/MRI and previa/accreta

Considering the significantly increasing risk of placenta previa and accreta as the number of prior cesareans increase, the fact that accreta as a 7% maternal mortality rate (due to hemorrhage) and a very high hysterectomy rate (one study found 71%), I do think it’s reasonable, especially if planning an out-of-hospital VBAMC, to have a ultrasound to rule out previa and even an MRI to try to rule out accreta.  (Keep in mind that the 7% & 71% statistics are based on hospital births where women have access to blood products, surgeons, and operating rooms and that if a mom has previa, the likelihood she has accreta rises dramatically.)

While MRI is more accurate for ruling out accreta than ultrasound, though there is no 100% accurate method thus far.

Read more on diagnosing accreta via ultrasounds versus MRI here.  You can also check out ACOG’s committee opinion on diagnostic imaging during pregnancy though accreta and previa are mentioned in passing.

What difference does it make if you know you have accreta before delivery?

Hospitals plan very differently for a delivery when accreta has been diagnosed.  Please go here for more detailed info.

Evidence to suggest previa less likely to “move” in VBAC/VBAMC moms

One large study has found that a previa is less likely to move away from the cervical os if the mother has a history of prior cesareans.  Please go here for more.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.  Read more about planning a VBAC.

VBAC bans, exercising your rights, and when to contact an attorney

legal-gavel-booksA mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

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Jen,

First thank you for your site!

I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing.

Quoting from your site quoting the ACOG bulletin:

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC.

If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

_____________________________

Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

“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.

Just kicking the can of risk down the road

This is why cesareans should not be casual or performed for the convenience of anyone.  They should be reserved for real medical reasons so that the benefits of having the cesarean outweigh the risks.  And there are real risks to cesareans, but since the ones list below are future risks, they may seem less real.  Per a November 2011 study published in the Journal of Maternal-Fetal and Neonatal Medicine:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Placenta previa and accreta are nothing to mess around with.  Accreta in particular has a very high maternal mortality rate and many mothers end up having cesarean hysterectomies.   I write more about accreta here.

Many women do not think these complications are applicable to them as they don’t plan on more children after their two cesareans.  But I know many women, and I’m sure you do too, who were not planning on more children, but got pregnant nonetheless.  Unless you or your partner get sterilized or practice abstinence (what fun!), the chance of you getting pregnant is there.

By performing routine scheduled repeat cesareans, we do reduce the risk of uterine rupture in the current pregnancy, but we are also increasing the risks of accreta, previa, maternal death as well as uterine rupture in future pregnancies.  In addition, another large study found

[t]he risks of placenta accreta, cystotomy [surgical incision of the urinary bladder], bowel injury, ureteral [ureters are muscular ducts that propel urine from the kidneys to the urinary bladder] injury, and ileus [disruption of the normal propulsive gastrointestinal motor activity], the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries.

And this is especially relevant in rural hospitals which institute VBAC bans because they don’t offer 24/7 anesthesia.  Even though the “immediately available” clause was removed in the latest (2010) ACOG VBAC Practice Bulletin, many of these bans still stand.

However, in order to rapidly respond to the potentially sudden diagnosis of accreta, previa, or abruption, the hospital will have to enact many of the same ideas provided at the 2010 NIH VBAC Conference on how a hospital without 24/7 anesthesia can safely offer VBAC and respond to uterine rupture.  So why not just institute those ideas from the get-go and offer VBAC to those who want it?  (I know, I know: medico-legal reasons, which the NIH also addressed, but that is another post.)  From VBAC Ban Rationale is Irrational:

 As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC [at the 2010 NIH VBAC Conference] 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.

Read more about the how the risk of serious complications increase with each cesarean surgery.

Below is Silver’s (2006) study abstract:

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. Epub 2011 Mar 7.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. Source Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Abstract

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study’s goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS: A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS: If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS: If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

http://www.ncbi.nlm.nih.gov/pubmed/21381881

hospital-vbac-bans

Mom encounters VBAC ban and requests advice

hospital-vbac-bans

Amber recently left this comment on the Quick Facts page:

i am pregnant for the second time my first child was delivered by c-section my goal is to have my second child natural but the obgyns in my area will not allow someone who has had a c-section to have a natural birth they said it is hospital policy what would you recommend?

Amber,

First educate yourself and then you can take action. You have many options.

I suggest you review the following documents and provide a copy to your health care provider: the most recent ACOG VBAC guidelines, the National Institute of Heath’s 2010 VBAC Statement, and the article VBAC ban rationale is irrational.

Next, read through the steps of planning a VBAC and familiarize yourself with the misinformation that some OBs have used to persuade women to schedule repeat cesareans, so if you hear these same lies, you can identify them: Another VBAC Consult Misinforms, Scare tactics vs. informed consent, Hospital VBAC turned CS due to constant scare tactics, VBACing against the odds, and A father says, Why invite the risk of VBAC?.

Additionally, it’s important to know that there are many birth myths rampant on the internet that misrepresent the primary risk of VBAC by minimizing the risk of uterine rupture such as “the risk of uterine rupture in a VBAC mom is similar to (or double) that of an unscarred mom’s risk,” or “the risk of uterine rupture in an induced, unscarred mom is the same as a VBAC mom,” or “a VBAC mom is more likely to be bitten by a shark or struck by lightning than have an uterine rupture.” Again, all these statements are false. And if you see a blog report really low uterine rupture or mortality rates, it’s likely the result of incorrect math.

On to your question. . . Unfortunately, I don’t have any personal experience of pursuing a VBAC in a VBAC ban hospital because I planned a home VBAC in order to avoid all that (almost certain) drama in the hospital. So, I went to my Facebook peeps and got their suggestions and they did not disappoint!

Here are their ideas in their own words…

1. Let hospital administrators and the board of directors know.

Mamas that are passing on a hospital because of their VBAC policy, need to then write the hospital administrators and the boards of directors to tell them that they birthed at XXX Hospital instead of theirs because of their VBAC policy. Hospitals need to hear that they are losing births (aka $$$) because of their policies.

2. Find an ICAN chapter near you.

She needs to get in touch with her closest local ICAN chapter TODAY. They will know details on the exact situation in her area. She should not put stock in what one person tells her- there is a lot of misinformation and myth out there. She can find both a local chapter and information about fighting a VBAC ban at www.ican-online.org

3. Sign a waiver and exercise your legal right to refuse surgery.

I had a VBAC at a hospital where no doctor staff supported it but low and behold all the nurses were amazing! I went in at 5 cm and 3 hours later baby was in my arms. Strong support is a must – I had a midwife, my husband, mom and sister. Stay focused. Don’t sign anything- except the refusal of c/section form- get in there and push your baby out!

and . . .

I would encourage her to ask to see this policy & ask if she would be allowed to sign a waiver. Ask friends if anyone they know has VBAC’d there or at another area facility. I had an experience in my last VBAC where I was told of a “policy” that didn’t really exist except in that person’s mind.

and . . .

Under the right to informed decision making she has the right to say “no thank you”. Absent a court order for a cesarean they cant force her. I’m not a huge fan of the “show up pushing” crowd, but it may appeal to her. Or she could labor in a nearby hotel with a midwife or montrice to monitor the baby and then go in to the hospital at the last minute. Again, not a fan but we’re looking at options here.

and . . .

Regarding stories of VBAC-ban hospitals. I don’t have experience myself, as my VBAC was done with a CNM at a supportive facility – but I’ve attended a VBAC at a local hospital with a VBAC ban. Mama had a RCS [repeat cesarean section] scheduled (though she didn’t intend on going in) but went into spontaneous labor 6 days prior. She labored at home several hours until contractions were about 3 minutes apart. When we arrived and they realized she had a previous c/s, they began calling in a team to prep the OR.

The mama was beyond calm – and in the middle of labor – requested to speak with the staff. The nurses (there were maybe 4 in there?), the attending OB, and the anesthesiologist (who had already been paged for the spinal for surgery) were in her room (ready to wheel her to the OR). Between contractions, she quickly and quietly explained that she was aware it wasn’t typical policy to attend a VBAC, but she was there and it was their legal duty to treat her and she was exercising her legal right to refuse unnecessary surgery.

The nurses looked shocked, the anesthesiologist said something about he was clearly not needed, and the OB (who I swear was VBAC accepting but just was staffed at a VBAC-ban hospital) told her that she was correct, they had to treat her and couldn’t force her to do anything unless her baby was in danger but she’d need to sign quite a bit of paperwork documenting the situation. He had the most odd grin/smirk on his face while he said that as if to somehow thank her for having the nerve to stand up for herself. He left the room and we didn’t see him again until she was crowning.

I in no way, shape, or form feel that that scenario is typical of a VBAC-ban situation, but it was certainly enjoyable and entertaining to have experienced that with my client.

and . . .

I just refused the c-section at a VBAC ban hospital. With my first, I pushed for 4 hours, and he didn’t get past the 0 station (he was presenting transverse) — We lived too far away from the hospital for a homebirth at our own home, but I hired the homebirth midwife for concurrent care. She was going to monitor us at a hotel near the hospital for labor, but thankfully everything went so fast we just met her at the hospital. She served as doula there. I found out from an OB nurse that one of the OBs did support a woman’s right to refuse (though not enthusiastically). I knew I needed care I could trust, so that the only c-section I got was medically necessary. You can read where my midwife tells our story here.

You have every right to refuse an unnecessary c-section, I’d just HIGHLY recommend laboring out of the hospital, and having a doula or knowledgeable advocate with you!

and . . .

This is my advice for VBACing at a banned hospital –
– Sign your informed refusal ahead of time, and be aware that when presented with the risks of VBAC, it will majorly underplay RCS risks; it might be a good idea not to bring your husband to this appointment if he’s feeling nervous about VBAC. [Or have your husband read this article beforehand.]
– Don’t let them give you a late term ultrasound for anything other than a medical problem (in other words — refuse the late ultrasound for size)
– Plan to labor out of the hospital; use a monitrice if you are nervous about that, or a good doula
– Have a smart advocate with you at the hospital so you don’t have to fight any battles yourself and can just focus on laboring
– Get good prenatal care — I did acupuncture and chiropractic, and both of those people had offered to help me in labor if I needed; having that support and belief was very empowering, because my OB absolutely didn’t think we “could” VBAC
– Own your decision; don’t be wishy-washy… be stubborn… this is YOUR BODY. I had a personal mantra that I repeated to myself over and over, “I will only have a medically necessary c-section.”
– Learn ways to get through labor naturally; I really liked the strategies in “Birthing from Within” — even more than hypno or Bradley techniques
– Show up in advanced labor (I was complete when we got to the hospital)
– Know your personal hang-ups — I pushed for 4 hours with my son and am SO GLAD that I labored down in a small bathroom until my urge to push was really strong and spontaneous; I am so glad I wasn’t on the bed pushing for a long time, because this would have brought back too many bad memories and made me feel panicky, tired, and out of control. When I got on the bed to push, I was practically crowning. THAT was very empowering for a “failure to descend” mama

To bottom line – do what you have to to get the care you need, even with limited options; own your body and decision, and give yourself every advantage and tool that you can to help ensure success.

and a VBAC supportive OB who worked in a VBAC ban hospital says:

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

4. Ask a different person at the hospital.

Remember that not everyone is knowledgeable about VBAC or a specific hospital’s VBAC policy, even if they work at that hospital.

I have heard an OB tell a mother that her only option was repeat cesarean because the hospital didn’t allow VBAC. The director of Maternal Child Health said it absolutely wasn’t true and gave her the names of VBAC friendly providers.

5. Find another hospital via the VBAC Policies by US Hospitals database compiled by ICAN.

Remember you are buying a service. Why pay for something you don’t want. Shop elsewhere.

6. Find another provider and ask these questions.

7. Birth in another city, county, or state.

Know what you’re comfortable with, hire a doula as well as a midwife or doctor especially if you have a hospital birth, and do your research so you know your rights and options. I’m currently about to “relocate” to Seattle at 37 weeks, from Juneau, AK where there is a hospital VBAC ban at our one hospital in town so I can try to have a VBAC in a more supportive environment. I didn’t think I wanted to fight the VBAC ban while in labor, I’d rather do my political activism in a clearer state of mind! It has been a stressful journey but I know I’m doing what’s right for me so I’m feeling really good about things now. I know this isn’t an option for many and a few women since the beginning of 2011 have refused repeat c/s at our hospital. Good luck!

and . . .

Go somewhere else. . . I traveled 40 mins for my vbac in 2010 because the 6 hospitals around here wouldn’t let them either.

and . . .

I even know a family who crossed state lines to have her baby the way she desired because her states laws wouldn’t allow her.

Joy Szabo said

I found a sane doctor 5 hours away. I got slightly famous for it, too.

and I’ve heard of women traveling to Mexico to VBAC at Plenitude with Dr. José Luis.

8. Consider a homebirth.

Fighting the hospital system while trying to push out a baby is not a simple task. Yes, a support team can be a big help. Personally, I felt more comfortable staying home than going to the hospital with my boxing gloves. It’s a personal choice and she’ll have to see what she’s most comfortable with. At the end of the day, I played out both options in my mind and went with the one that I felt most at peace with.

and. . .

Hello, my personal story in a nutshell… iatrogenically necessitated c/s with my first. For #2, it was a last minute change of plans… I’m a physician and I discovered through the grapevine that OB was planning to resection me without medical indication so #2 turned into planned HBAC. Homebirth VBAC successful with my second. The second was so beautiful, so peaceful, so uncomplicated!

9. Connect with resources for more ideas.

Stratton, B. (2006). 50 Ways to Protest a VBAC Denial. Retrieved from Midwifery Today: http://www.midwiferytoday.com/articles/50ways_vbac.asp

A good closing thought:

The term “will not allow” always bothers me. Perhaps they “won’t attend a VBAC” but they definitely can not stop you. Stand up for your rights. Show them the ACOG recommendation which is to allow a trial of labor! Seek out support. Call every OB you can think of. Look into a midwife. Hire a doula. You can do this.

Do you have more ideas?

Did you deliver at a VBAC ban hospital?

What was your strategy?

Are you a health care provider at a VBAC ban hospital and have some insight?

no

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.

______________________________________________

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

Interview with Dr. Fischbein: An Inside Look at Hospitals and VBAC Bans

Stand and Deliver recently conducted an excellent interview with Dr. Stuart Fischbein, a Southern California VBAC and breech supportive OB.  It’s an excellent read and I’m including my favorite parts below.  You can read the entire article here: Stand and Deliver: Interview with Dr. Stuart J. Fischbein.

First, let’s do  quick review of ACOG’s Practice Bulletin #54, published in July 2004 and the reason why some American hospitals have banned VBAC, recommends, “a physician [be] immediately available throughout active [VBAC] labor who is capable of monitoring labor and performing an emergency cesarean delivery.”

Now that we are all on the same page, here are excerpts from Dr. Fischebin’s interview:

Don’t hospitals ban VBAC because it is dangerous?

They 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.

What role does malpractice insurance play in VBAC availability?

The reason that a lot of hospitals ban VBACs anyway [despite meeting ACOG’s “immediately available” recommendation] —and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety. The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Aren’t uterine ruptures the primary reason for repeat cesareans in women with a prior cesarean?

Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture.  They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations.  Far more often, it’s something unrelated to the VBAC that causes an emergency.  And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs?

ACOG’s latest VBAC recommendation was based on consensus opinion, not scientific evidence.  Doesn’t that matter to hospitals when implementing VBAC bans?

Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued.

Do hospital administrators impact how an OB counsels a woman on VBAC?

I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. … I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

How do OBs feel about working in hospitals with VBAC/breech bans?

For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

How do VBAC bans impact hospital revenues?

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; [the official reason for VBAC bans] will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

How do VBAC bans impact women seeking VBAC?

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth.

How could tort reform impact VBAC supportive OBs and birthing women?

[With] tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives.

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