C-section rates remain higher at Long Island hospitals despite risks

Doctors perform cesarean sections more frequently at Long Island hospitals than at counterparts elsewhere in New York, even though the surgery poses greater risks to mothers than vaginal births, a Newsday analysis found.

The 13 Nassau and Suffolk hospitals with maternity departments vary greatly in how often physicians use the procedure, a major surgery in which incisions are made in the abdomen and uterus to deliver the baby. The 48.5% of "low-risk" pregnancies at Port Jefferson's St. Charles Hospital that resulted in cesareans in 2024 — the highest rate in New York — were more than double the 20.7% at Long Island Jewish Medical Center in New Hyde Park, which had the region's lowest rate, according to data from The Leapfrog Group, a nonprofit that evaluates hospital safety and quality.

Experts agree that cesarean sections sometimes are medically necessary to save the life or protect the health of the mother or baby. But for women who are considered at low risk from a vaginal birth — defined by government agencies and Leapfrog as a birth involving a first, single baby at full-term with the baby headfirst in the birth canal — a cesarean carries a greater possibility of infections, blood clots, blood loss and serious problems with future pregnancies, research shows. In addition, post-birth recoveries usually are longer and more difficult, and the procedure is significantly more expensive.

Despite more attention in recent years to reducing C-section rates, they have barely budged nationwide, statewide or on Long Island. The statewide rate for low-risk births that led to cesareans in 2022, the most recent year for which the state Health Department released data, was almost identical to the rate in 2013.

Leapfrog's average for Long Island hospitals was 31% in 2024, compared with a preliminary average for hospitals statewide of 27.2%. The state has not released its own statistics on low-risk-cesarean rates by hospital, but information it collected on birth certificates through 2022 shows that Long Island for years had a higher cesarean rate than the rest of the state.

Why rates are higher at Long Island hospitals than elsewhere in New York is unclear.

Dr. John Vullo, chair of women's health for Catholic Health, which includes St. Charles, said he doesn't know why St. Charles' rate rose significantly between 2021 and 2023 before plateauing in 2024.

"I will do a deep dive at St. Charles," Vullo, who assumed his position on July 1, said in a telephone interview.

Vullo said his health system is taking steps to lower the rates, including educating doctors about changes in nationwide childbirth guidelines that are intended to reduce the number of unnecessary cesareans.

Doctors and nurses who oversee labor and delivery at hospitals with Long Island’s lowest rates said one way they brought C-section numbers down was by showing physicians how their cesarean numbers compare with those of colleagues.

At Long Island Jewish, any doctor with a rate of more than 30% sits down with hospital officials to discuss their decision-making, said Dr. Kevin Holcomb, chair of obstetrics and gynecology at Long Island Jewish and North Shore University Hospital, both part of Northwell Health. At Mount Sinai South Nassau in Oceanside, which has the region's second-lowest rate, physicians and nurses go over every unscheduled cesarean case to determine whether it was appropriate, said Patricia Bartels, the hospital's nurse manager for labor and delivery.

Whether doctors and hospitals view cesareans as common or as an operation to turn to only when necessary will help determine how frequently the surgery is performed, said Martine Hackett, who researches maternal and child health at Hofstra University and chairs its population health program.

"It comes down to the culture of a particular place, what’s considered to be normal," she said.

It also depends on when and what physicians were taught, and whether they are up to date on and follow current recommendations, Holcomb said.

"Sometimes the things that have been imprinted on you from training can be really, really strong and hard to reverse," he said.

There also is the fear of a malpractice lawsuit if there are complications with a vaginal birth that lead to physical or developmental issues with the child, or health problems for the mother, said Dr. Lisa Nathan, chief of obstetrics at NewYork-Presbyterian Columbia University Irving Medical Center in Manhattan.

In malpractice suits involving vaginal births, "very often the question becomes, ‘Why didn’t you just do a C-section earlier?’ ” she said.

Increasing concerns about litigation, along with medical advances, are two of the main reasons the percent of births that were cesarean shot up from 5.5% nationwide in 1970 to 24.7% in 1988, according to federal data and analyses and interviews with experts.

There is disagreement as to whether there is a financial incentive to perform C-sections, which, as major surgeries, typically are much more expensive.

A study released in 2021 found that women were more likely to undergo cesareans if they delivered at hospitals with higher profits per cesarean surgery.

But hospital associations say there is no incentive. Even when hospitals receive more reimbursement for cesareans, "you are incurring much greater costs in those cases," including from longer hospital stays and more clinical professionals, said Wendy Darwell, president and CEO of the Suburban Hospital Alliance, which represents Long Island and Hudson Valley hospitals.

Doula: Patients pressured

As a doula helping support Long Island and Queens women during pregnancy and childbirth, Lené Elizabeth Warren said she repeatedly sees doctors pressuring her clients to have cesareans, despite the women's vocal preferences for vaginal births. Sometimes the women relent, later regretting missing out on what they had envisioned as a more natural, joyous experience, she said.

"They were thinking that the doctors are the medical providers, and they know better," said Warren, of Far Rockaway, Queens.

Rachel Goodale, owner of Stroller Strong Mamas in Aquebogue, a fitness group for parents and children, said clients often discuss how certain doctors have a reputation for pushing low-risk patients to have cesareans. She recalled how her own physician pressed her husband to tell her to have a C-section when she was giving birth to her son Reece in 2015, because the doctor thought labor was lasting too long.

"I demanded I do it naturally," she said, and gave birth a half hour later.

Rates sometimes vary greatly among doctors and within health systems. St. Charles' 48.5% rate contrasts with a 29.6% rate at another Catholic Health hospital, Mercy Hospital in Rockville Centre.

Although Long Island Jewish in 2024 had the lowest C-section rate on Long Island, Northwell’s five Island hospitals with maternity departments had a wide range of rates, with Riverhead's Peconic Bay Medical Center at 36%, the region’s third highest.

Holcomb said at a smaller hospital like Peconic Bay, one or two doctors can greatly affect rates. But he said Northwell systemwide is trying to safely decrease low-risk-cesarean rates, using similar techniques at each hospital.

Northwell and other health systems do not publicly release rates by doctor, and even their physicians see only colleagues' rates, not their names.

Officials of two of the five other Long Island hospitals with the highest rates — Nassau University Medical Center in East Meadow and Stony Brook University Hospital — said in emailed statements that one reason their numbers were so high is because they, compared with other hospitals, treat a greater proportion of pregnant women who have health conditions that increase risk.

Not all pregnancies defined for statistical purposes as low-risk are truly low-risk, because women or babies may have cardiac issues or other health problems that may necessitate a cesarean, Nathan said.

Stony Brook is a state-designated center for pregnant women and newborns who require complex care, and that contributes to the hospital's high cesarean rate, although Stony Brook is actively trying to reduce the number of C-sections, according to a hospital statement. Hospital officials declined to be interviewed for this story.

Yet Long Island Jewish is another of the 17 state-designated centers for the most complex cases, and its 20.7% rate contrasts with Stony Brook's 36.1%.

Officials at NYU Langone Hospital-Long Island in Mineola, another state-designated center, with a 29.8% rate, did not respond to requests for comment.

Racial disparities

Only about 2.5% of women request cesareans in advance, according to the American College of Obstetricians and Gynecologists. Studies on childbirth and Newsday interviews indicate that many women want the experience of what they view as a more natural birth, and they want to avoid the typically longer and more arduous recovery from a C-section.

Poppy Slocum, 41, had been hoping for a vaginal birth when she arrived at Stony Brook in 2012. But difficulty in keeping the baby's heart rate up led to a cesarean.

"It was a traumatic experience," said Slocum, a former Stony Brook resident who now lives in Brooklyn. "You're being cut into."

"Laughing, coughing, sneezing were really, really terrible," said Slocum, who delivered the baby as a surrogate mother. "Any change of position was painful, especially at the beginning. I can't imagine taking care of a child during recovery."

Alicia Lewis, 40, of Central Islip, also had wanted a vaginal birth. But when her daughter was being born in 2012, she was sideways in the birth canal, so Lewis had a C-section.

She not only had, like Slocum, weeks of pain and discomfort. She also had an infection that put her back in the hospital for eight days.

Infections are significantly more common after cesareans than with vaginal births, studies show.

With the higher risks associated with cesareans, New York and other states are examining racial gaps. Black women are 20% more likely to have C-sections than white women, even when controlling for factors such as medical risk, a study of more than a million New Jersey birth records released last year found. In New York, 34.1% of Black women with low-risk pregnancies had cesareans between 2020 and 2022, compared with 27.9% of white women, state Health Department data shows.

Lewis, who is Black, said she was told it wasn't safe to try to turn her baby, and she gave her OK for a cesarean.

But in other cases, said Warren, a doula, even when there is no indication of potential harm to the mother or baby, physicians often are dismissive of women’s wishes for a vaginal birth, especially when the women are Black.

The racial disparities in low-risk-cesareans are one reason the state in recent years has ramped up its efforts to reduce C-section rates.

Long Island Jewish and South Nassau are the only two Long Island hospitals that have met the U.S. Department of Health and Human Services' goal of a low-risk-cesarean rate of 23.6% by 2030.

New York's 28.3% rate in the 2023 Leapfrog analysis was the nation's second highest, after Mississippi, although for roughly a third of hospitals surveyed, Leapfrog's data is based on sampling, not on all births, and not every hospital supplied data to the organization, said Jean-Luc Tilly, Leapfrog’s program director. Nationwide data for 2024 is not complete because some hospitals have not yet submitted their numbers.

State Health Department spokeswoman Cadence Acquaviva said the state uses more complete data to calculate statewide low-risk rates: birth certificates. Using that method, the state's rate in 2024 was 29.2%, ranking it seventh highest among states and the District of Columbia, according to the Centers for Disease Control and Prevention, whose ranking is based upon birth certificates.

Rates can come down when doctors and hospitals focus on the impact of cesareans on their patients, said Dr. Jonathan Rosner, director of obstetrical quality at South Nassau, which has seen its cesarean rate plummet over the past several years amid a targeted reduction effort.

In addition to the greater chance of infections and other complications, and the typically more difficult recovery, women can be emotionally scarred by wanting and expecting a vaginal birth and then suddenly undergoing a C-section, Rosner said.

"There’s a grief with not having your birth going the way you wanted it to go."