In the early months of 2016, a remarkable shift quietly began within the obstetrics department at Princeton Baptist Medical Center, a longstanding hospital in Birmingham, Alabama. Dr. Jesanna Cooper, an experienced obstetrician who had practiced there for nearly a decade, saw her team expand through the hiring of a certified nurse-midwife. Remarkably, this was the first midwife employed at the hospital in roughly two decades—a decision that would soon transform the institution’s approach to maternal care. The addition of a professional trained in the midwifery model of care—one that emphasizes physiology, patience, and minimal intervention—instantly began reshaping the delivery landscape. Cooper quickly observed a dramatic improvement: she was able to support a far greater number of vaginal births with confidence and safety, and as a direct result, her personal rate of cesarean sections, or C-sections, declined sharply.
What Cooper experienced was not an isolated phenomenon. Between the years 2018 and 2023, obstetricians at Princeton Baptist performed surgical deliveries on fewer than one out of every six women with low-risk pregnancies, as reported in a large-scale analysis conducted by Business Insider. This meant the hospital’s average C-section rate was almost half the statewide average in Alabama, and substantially lower than any other hospital within the city of Birmingham. These outcomes, as Cooper described, were the result of an enduring and difficult battle—a determined resistance not just against administrative inertia, but also against the broader systemic tendencies of the American medical system, which often rewards efficiency and profitability over patient-centered, time-intensive care. Reducing unnecessary surgeries meant pushing for more nurses, additional labor beds, and a cultural shift away from the financial logic that defined so many hospital corridors.
While cesarean birth is an invaluable medical intervention in cases where complications threaten the life or health of mother and child, experts have long cautioned that the surgery is performed far more frequently than is medically necessary. Across the United States, physicians carry out C-sections at about twice the rate considered “ideal” for optimal maternal and infant health according to the World Health Organization. The United States also significantly exceeds the rates found in nations with strong maternal outcomes such as Finland and Sweden. Importantly, this overuse is not driven by patient demand—only a small fraction, approximately two and a half percent of all births annually, are elective C-sections requested by the mothers themselves. Instead, structural and economic motives play a powerful role. The procedure tends to be more profitable for hospitals and financially safer for practitioners concerned about malpractice litigation. In a system where healthcare institutions must continually balance patient care with fiscal sustainability, unnecessary surgeries can become subtly incentivized.
When Business Insider examined C-section rates across more than 1,700 hospitals spanning 29 states and Washington, D.C., the data revealed striking disparities. Even neighboring hospitals serving similar patient populations often exhibited drastically different surgical intervention rates. The analysis suggested that hospital ownership and structure—particularly whether a facility operated as a for-profit entity—strongly influenced these outcomes. Such patterns underscore how institutional culture, management decisions, and economic frameworks can directly shape clinical practice.
Several physicians and administrators interviewed for the investigation described ongoing efforts to reduce C-section rates through deliberate, evidence-based methods. For example, at Palisades Medical Center, Dr. Manuel Alvarez explained that his team implemented monthly training sessions, standardized care protocols grounded in scientific evidence, and fostered a cooperative environment where both nurses and physicians shared responsibility for minimizing unnecessary surgeries. Similarly, some hospitals closed or consolidated obstetric services entirely in response to changing delivery volumes, while others doubled down on improving vaginal birth support.
Despite these successes, doctors across the country emphasized the enormous pressures inherent in obstetric decision-making. Childbirth can turn from routine to life-threatening within moments, and the legal consequences of an adverse outcome are immense. A 2023 study confirmed that obstetricians are among the specialties most likely to face at least one malpractice claim during their careers. Fear of such lawsuits, and the financial devastation they can bring, often pushes clinicians toward the perceived safety of surgical intervention.
Yet, the reporting also revealed optimism: cesarean rates are not an unchangeable fixture of the American healthcare landscape. Experts pointed to hospitals like Princeton Baptist as proof that meaningful reductions are possible when leadership invests in the necessary staff, time, and policies that support vaginal deliveries. Across more than a century of clinical history, cesarean surgery has evolved from a rare, lifesaving measure to the most common inpatient operation in the United States—accounting for over 32 percent of all births. Maternal health researchers estimate that nearly 13 percent of these surgeries could be avoided without endangering mothers or newborns, translating to hundreds of thousands of women each year exposed to unnecessary surgical risk.
Hospital-to-hospital variation highlights how profoundly institutional priorities can shape outcomes. At one extreme, certain facilities report cesarean rates below 5 percent, while others approach or exceed 60 percent. Princeton Baptist’s performance stood out in national analyses, particularly for women categorized as low-risk—those delivering a single, head-down infant at full term for their first birth. The hospital’s low rates were especially notable given its location in a predominantly Black, lower-income neighborhood, where national data show women often face higher rates of medically unnecessary intervention. Cooper attributed this success largely to collaborative practice with midwives and sufficient staffing levels that enabled longer, uninterrupted labors. Without adequate nurses, space, or time, she explained, the default tendency becomes intervention.
Contrastingly, other hospitals—particularly for-profit institutions—continued to report alarmingly high surgical birth rates. At one Texas hospital, more than half of all births over seven years occurred by C-section, with nearly all women who had previously undergone the surgery repeating it in subsequent pregnancies. Experts agree that first-time cesareans should be avoided whenever safely possible since they almost inevitably lead to repeat surgical deliveries. For researchers, the most telling statistic is the C-section rate among low-risk cases, which effectively reflects a hospital’s approach to labor management and patient-centered care. Studies confirm that a woman’s likelihood of undergoing an unnecessary C-section depends less on her personal health profile and more on the hospital where she delivers.
Ultimately, the analysis revealed a consistent pattern: economic incentives remain a central driver. Because most U.S. hospitals function under fee-for-service reimbursement models, every procedure—and every baby delivered—translates into a billable event. A cesarean birth, being quicker and more predictable, not only commands a higher average reimbursement than a vaginal delivery but also reduces the lengthy labor time that ties up staff and resources. This renders surgery more efficient from a business standpoint, even if it runs counter to best medical practice. In for-profit hospital chains, where shareholder expectations emphasize quarterly returns, the pressure to maintain or increase revenue further tilts the system toward high intervention.
The American College of Obstetricians and Gynecologists, in its 2025 guidance, urged hospitals to counteract these trends by cultivating a professional culture that actively encourages vaginal birth when safe. The recommendations emphasize continuous staff education, consistent interpretation of fetal monitoring, and adequate nurse-to-patient ratios—factors proven to reduce C-section rates. Unfortunately, these staffing levels often fall short, partly because nursing constitutes a hospital’s largest variable expense. Financially constrained facilities frequently opt to reduce nursing coverage first, a decision that can directly elevate surgical delivery rates. Studies show that hospitals able to assign one nurse to each laboring patient average notably fewer C-sections than those stretched thin.
Princeton Baptist earned national recognition for its high-quality maternal care, named by major publications among the country’s best maternity hospitals. However, the very conditions that allowed that success—ample nursing support, extended labors, and intensive patient monitoring—also made the department less financially sustainable. Despite a substantial 70 percent increase in the number of births between 2018 and 2022, revenue could not offset the extensive overhead costs entailed in providing slow, hands-on labor care. Dr. Cooper recalled the constant institutional pressure to deliver more babies more quickly, illustrating the central tension between medical best practice and economic necessity. In 2023, that tension reached its limit when Tenet Healthcare, one of the largest for-profit systems in the nation, closed Princeton Baptist’s labor and delivery department. It was one of more than 500 such closures across the country since 2010, each one reshaping access to maternal care in its community.
Deliveries were redirected to the larger Brookwood Medical Center nearby, where doctors performed low-risk C-sections at twice the rate previously maintained at Princeton Baptist. For Dr. Cooper, the closure marked the culmination of years of struggle; burnt out and disheartened, she left the practice in late 2022. Her departure underscored a broader existential fatigue experienced by many physicians attempting to reconcile ethical care with systemic economic pressure. As one veteran researcher noted, hospitals tend to revert to the national average C-section rate once special initiatives end—a phenomenon driven not by medical necessity but by what the healthcare market deems “acceptable outcomes at acceptable cost.”
Nevertheless, there are flashes of hope. Some states, including California, Iowa, and New Jersey, have launched coordinated programs aimed at standardizing best practices and reducing medically unnecessary cesareans. In early 2025, Alabama followed suit, as dozens of its hospitals voluntarily joined a statewide effort to reduce first-time C-section rates by 20 percent within two years. While not all institutions have chosen to participate—particularly those with historically high rates—the initiative represents a growing recognition that reform is possible when patient safety, not profit, defines the metric of success.
Sourse: https://www.businessinsider.com/c-section-hospital-rates-differences-data-analysis-2025-12
