How C-sections impact healthcare costs — and what employers can do

If complications arise in pregnancy or during labor, birth by Cesarean section (C-section) can be a lifesaving medical intervention. While the availability of this surgery is vitally important, C-section rates in the U.S. are significantly higher than necessary, according to public health experts. Unnecessary C-sections can increase the risk of complications both for the person carrying the pregnancy and the baby — and raise healthcare costs.

In some cases, C-sections are unavoidable and are necessary to reduce the risk of injury and even death. However, in other cases, a vaginal birth may still be an option. For example, in my practice, I see an astounding number of individuals tell me they did an elective C-section for reasons that are not considered “necessary” or “urgent/emergent,” such as:

• “I wanted to have the baby on a specific date.”
• “I wanted to make sure my doctor was delivering me and not someone else in his/her practice, so we scheduled a C-section.”
• “I had a C-section before and was told I needed a repeat C-section. No one discussed vaginal birth after cesarean (VBAC) with me.”
• “I asked to be delivered early and didn’t want to wait to go into labor.”

At Carrot, our members are educated on options for birth including VBAC, how to discuss your preferences with your provider, birth plans, and reasons for C-section. Educating individuals on their options and avoiding unnecessary C-sections can help reduce risks and prolonged hospitalizations for the individual and also help to reduce healthcare costs.

Why higher C-section rates can be an issue

While common, a C-section is still considered a major surgery. The procedure requires a large abdominal incision through multiple tissue layers and a uterine incision that's close to other major vital organs. This means there is a longer recovery time than vaginal delivery and a higher risk for pain, infection, bleeding, injury, and prolonged hospitalization.

Another potential risk of having a C-section is a higher risk profile for future pregnancies, such as uterine rupture or placenta previa. When comparing these risks against life-threatening pregnancy and birth complications, of course, the benefits win out — but only when medically necessary.

On the logistical side, C-sections are costlier than vaginal births: the average reimbursement for performing C-sections is approximately 50% higher than it is for vaginal births. Longer hospital stays and recovery time can also contribute to higher costs for patients and employers.

Understanding the C-section rate in the U.S.

Globally, C-section rates are higher than are medically necessary. Over the years, many studies have looked into what ideal C-section rate is associated with a decrease in maternal, neonatal, and infant mortality — and the majority of them are all under 20%. Higher C-section rates do not lead to a reduction in mortality risk or improved outcomes, even taking into consideration socioeconomic factors.

The U.S. national average is an alarming 32%, which is much higher and suggests we’re performing more C-sections than medically necessary.

Why might C-sections happen more often than they medically need to in the U.S.?

• Clinical gray areas around this decision-making
• Requests for C-section (which experts don’t recommend before 39 weeks due to higher rates of additional C-sections in later pregnancies)
• The pressured environment these decisions are made in
• Risk-averse hospitals trying to avoid complications and litigation
• The higher pay for C-sections versus vaginal births
• Cultural acceptance of and preference for C-section birth in different countries

As important as C-sections are when they’re medically necessary, seeing a rate that is disproportionately higher than it is helpful for birth and infant outcomes tells experts that we’re performing surgery in situations that don’t warrant it. When C-sections are performed that aren’t medically necessary, the possible risks do not outweigh the benefits.

What can help reduce the C-section rate?

While no one can be in complete control of life events like pregnancy and childbirth, research shows that the following care providers and clinical decisions can increase the likelihood of vaginal delivery.

1. Midwife or collaborative care: When midwives are involved in care, either as the sole provider in low-risk pregnancies or in collaboration with an OB/GYN, there are lower reported rates of C-sections.

2. Working with a doula: There is substantial evidence that continuous labor support from a doula or other support person improves outcomes — including higher rates of vaginal delivery and decreased instrumental deliveries.

3. Single embryo transfer for in vitro fertilization: In the past, transferring multiple embryos was the standard of care for in vitro fertilization (IVF). Now we know that voluntary single embryo transfer (SET) is associated with higher rates of singleton pregnancy without affecting overall success rates, as well as lower rates of C-section.

4. Education on birthing options: Many pregnant people do not realize all their birthing options including relaxation techniques, pain management, and vaginal birth after C-section. Studies have shown that prenatal education, including in the form of courses, can help reduce C-section rates.

Because we know how much pregnant people can benefit from these aspects of care, we’ve embedded them into our pregnancy support.

Pregnancy support at Carrot

As an employer, you have the opportunity to offer benefits that support your employees’ family-planning goals — whatever they may be.

At Carrot, we offer a suite of supportive resources to bring your employees comprehensive care and guidance that can help promote healthy pregnancies and desired birth experiences. With Carrot, members can:

• Chat with midwives, doulas, and other experts: Carrot connects members with a wide range of experts, including midwives and doulas, for unlimited access to guidance and support.

• Use Carrot funds to cover doula services: Doula care isn't typically covered by insurance. Members can use their Carrot funds to pay for care from doulas.

• Get guidance about SET from Carrot care navigation: Our medical expert team communicates the benefits of SET and other points of clinical decision-making to members so they can make informed choices about their pregnancies. In fact, Carrot has a SET rate (97%) that’s more than 25% higher than the national average (77%).
• Access pregnancy group sessions and guides: In addition to 1:1 support and education, Carrot provides structured expert-led pregnancy group sessions to help educate members and improve pregnancy outcomes through community-based learning. In addition, Carrot members have access to in-depth educational guides on birthing methods, and can receive assistance on birthing plans and how to discuss them with one’s provider.

Interested in seeing how else you can support your employees through healthy pregnancies? Get in touch today.