How 3 Long Island hospitals lowered their C-section rates

Although cesarean section rates have been roughly stagnant for years statewide and nationwide, some Long Island hospitals have made dramatic progress in reducing the percentage of low-risk pregnancies that result in C-sections.

In 2017, more than 40% of low-risk pregnancies at Mount Sinai South Nassau — then called South Nassau Communities Hospital — ended in cesareans, according to The Leapfrog Group, a nonprofit that focuses on hospital safety and quality. By last year, the rate had fallen to 21.5%.

"It was a concerted effort from both the physician side and the nursing side to get these numbers down," said Dr. Alan Garely, chairman of obstetrics and gynecology at the Oceanside hospital.

In the past, the maternity department had taken a "physician-first" approach to labor and delivery, said Dr. Jonathan Rosner, director of obstetrical quality at South Nassau. The doctor alone made decisions and often did not seek input from others, he said. Now, he said, nurses and others are part of decision-making, and if there are differences of opinion, the issue is discussed as a group.

Nurses' insights, and their help with correctly positioning pregnant women and taking other steps, can help avoid unnecessary cesareans, said Joyce Edmonds, chair of the department of nursing at the University of Massachusetts Boston. She co-authored a 2017 study that found that rates of C-sections vary greatly depending on the nurse who was assigned to a labor and delivery.

Patricia Bartels, nurse manager for labor and delivery at South Nassau, said nurses and doctors analyze and discuss all unscheduled C-sections after they're performed.

Bartels saw the collaborative process firsthand in April, when her daughter, Elizabeth Sweeney, 31, was in labor at South Nassau. Sweeney had gone through 48 hours of early labor with little progress in her cervix dilating, and the baby was in a diagonal position, Bartels said, meeting the C-section guidelines of the American College of Obstetricians and Gynecologists, the leading professional group for OB-GYNs.

Bartels gently broached the possibility of a C-section with her daughter, "and she was like, ‘I don’t want to do that.’ ”

As Sweeney's son Ryan, now 4 months old, fidgeted while sitting on her lap in their Rockville Centre living room, Sweeney recalled that the doctor told her that he would perform a C-section as a last resort, but he didn't think it would be necessary.

"When he gave me that little bit of hope, I was like, ‘Let's take this and run with it,’ ” Sweeney said.

"We try to give them as much time as they need," Bartels said of South Nassau.

Sweeney gave birth to a healthy Ryan with the vaginal birth she had always wanted.

'I have to get home'

Before arriving at South Nassau in 2020, Bartels had worked at two other hospitals, one in Manhattan and the other on Long Island. At those hospitals, some physicians didn’t hide that they wanted to perform a C-section because they wanted to get off work, she said.

"There are people who are like, ‘I have to get home, I have stuff to do, I have a life,’ and it does impact the C-section rates," she said.

There gradually were fewer C-sections based on physician convenience after the American College of Obstetricians and Gynecologists released its guidelines in 2014, Bartels said. They were updated last year.

Like South Nassau, Long Island Jewish Medical Center in New Hyde Park and North Shore University Hospital in Manhasset tell their physicians how their low-risk C-section delivery rates compare with those of their colleagues, whose names are anonymized.

"Without giving people that context, they may not realize they’re ahead of the mean or below the mean," said Dr. Kevin Holcomb, chair of obstetrics and gynecology at the two Northwell hospitals.

Anyone with a rate of more than 30% must have a meeting with hospital officials, he said, and cesarean rates are part of annual performance evaluations. Doctors who have lower rates or are making progress are singled out for praise, Holcomb said.

Physicians with higher rates may not know that guidelines have changed and how, for example, having a woman sit upright with an inflatable birthing ball is more likely to lead to movements that facilitate vaginal birth than leaving the woman flat on her back the entire time, he said.

"We want to make sure that we're safely promoting vaginal delivery," he said, "not just reducing C-sections for the sake of reducing them."