Getty Images; Alyssa Powell/BI
In the spring of 2016, obstetrician Dr. Jesanna Cooper's practice hired a nurse-midwife to deliver babies at Princeton Baptist Medical Center, a hospital in Birmingham, Alabama. The nurse-midwife was the center's first in about 20 years.
The impact on care was transformative, said Cooper, who practiced at Princeton Baptist for nearly a decade. She learned to safely support far more vaginal deliveries, and the number of C-sections she performed soon plummeted, she said.
Cooper wasn't alone. Between 2018 and 2023, doctors at Princeton Baptist on average cut into fewer than one in six women with low-risk pregnancies, according to data analyzed by Business Insider. The hospital's average rate in those years was nearly half of Alabama's statewide average, and dramatically lower than all of Birmingham's other hospitals, according to Business Insider's analysis.
The success was bitterly won. Delivering more babies vaginally was a years-long, "all-out, knock-down fight" against the hospital's administrators and the momentum of the US medical system, Cooper said. It was a fight for more staff; a fight for more time and beds for laboring women; and a fight against a medical system that rewards a different metric: profit.
Though C-sections can be vital, often life-saving surgeries, they're a frequently overused major abdominal surgery. US doctors perform them at double the rate the World Health Organization says is "ideal" for maternal and infant health, and nearly twice the rate of Finland and Sweden.
Women aren't asking for more C-sections; 2.5% of US babies are born by elective C-section each year. Instead, experts say, C-sections are more lucrative and cost-effective than vaginal deliveries, and are perceived to be more protective in the event of an expensive malpractice lawsuit. Hospital systems looking to maximize revenues and keep operating costs low are indirectly incentivized to keep surgery rates high.
How each hospital is run dramatically impacts how many surgeries its doctors perform, and C-section rates can swing wildly from hospital to hospital.
To track this, Business Insider analyzed C-section rates at over 1,700 hospitals with an average of at least 100 births each year, from 29 states and Washington, DC.
At hundreds of hospitals in Business Insider's analysis, surgeons performed C-sections at far higher rates than doctors practicing at the nearest neighboring hospital, likely serving similar patient populations.
The data suggests that for-profit healthcare systems appear more susceptible to high rates.
Vijay Chaudhuri, a vice president of Hudson Regional Health, the parent company of Hudson Regional Hospital, now known as Secaucus University Hospital, told Business Insider that the hospital closed its labor and delivery department in April, 2023, and did not otherwise respond to Business Insider's reporting.
Dr. Manuel Alvarez, who oversees care at Palisades Medical Center, said hospital leadership made a concerted effort to lower C-section rates and safely support more vaginal births, which included routine monthly trainings, evidence-based care protocols, and promoting a workplace culture more supportive of vaginal deliveries.
"The rate of C-sections is something we have been addressing," a spokesperson for East Los Angeles Doctors Hospital's parent company said in a statement to Business Insider. The spokesperson said the hospital planned to close its obstetrics department in January 2026 "due to declining deliveries over the last year."
Spokespeople for Providence Memorial, Las Palmas Medical Center, Adventist Health White Memorial, and Merit Health Biloxi, now known as Memorial Hospital Biloxi, did not respond to Business Insider's queries by phone and email.
Doctors delivering babies make tough calls. The stakes are high, doctors told Business Insider, and a routine delivery can quickly turn into an emergency that requires immediate surgery.
Many providers also told Business Insider that C-sections are often performed because doctors fear the crushing expense, professional damage, and personal distress suffered in a malpractice lawsuit. C-sections are perceived to be more protective in the event of a lawsuit alleging injury to a baby. Obstetricians are among the doctors most likely to face a legal threat at least once in their career, a 2023 study found, and a lawsuit filed over the serious harm or death of a baby can result in tens of millions of dollars in jury awards.
Business Insider's reporting showed that C-section rates aren't intractable. Experts said that rates can safely come down at hospitals that prioritize making careful, evidence-based changes.
"Some providers say this is too big for me," Cooper said, "but some try to fight it."
At Princeton Baptist, Cooper and the labor and delivery team fought to safely support more women to deliver vaginally. For a while, they won.
The most common inpatient surgery in America
C-sections are the most common inpatient surgery in the country. More than 32% of all babies born in the US are delivered by C-section. Many could likely have been avoided, maternal health experts say. One large study estimates that up to 19% of all births should be C-sections to protect women and their babies, leaving as many as 13% possibly performed needlessly in the US.
That suggests that around one in 10 pregnant women in the US — as many as half a million women each year — undergoes a medically unnecessary C-section, leaving her at higher risk of blood clots, hemorrhages, infections, and more likely to develop dangerous complications in future pregnancies.
Not all hospitals perform these surgeries evenly. Cesarean surgery rates across US hospitals swing to extremes, dipping as low as 4% overall at a hospital in Alaska and as high as 62% overall at a hospital in Florida, according to Business Insider's analysis.
At Princeton Baptist in Birmingham, Cooper and her colleagues maintained one of the lowest rates of C-sections performed on women with low-risk pregnancies — those who are pregnant for the first time, are at full term, are not delivering twins, and whose babies are head-down rather than breech — of any hospital in Business Insider's analysis.
In many ways, it was an outlier.
The hospital is located in a low-income, Black-majority neighborhood of Birmingham, Alabama. Nationwide, Black women are more likely than other women to undergo medically unnecessary C-sections.
Cooper credited most of their success to working with midwives. Across the US, women with low-risk pregnancies cared for by midwives have better health outcomes and lower chance of undergoing a C-section, according to several recent studies.
Cooper also said she and other providers at Princeton Baptist had enough staff and available beds to support women in long vaginal deliveries.
"If you don't have enough nurses, you don't have enough beds, or you don't have space for women to labor," said Cooper, "you're going to do things that increase the risk of a section."
Dr. Manuel Alvarez, who also chairs obstetrics, gynecology, and reproductive science at Hackensack University Medical Center and the Hackensack-Meridian School of Medicine, said his hospitals track individual and share provider C-section rates, hold routine monthly trainings on supporting vaginal deliveries for doctors and nurses, and implemented evidence-based protocols to ensure "women have the best chance of a vaginal delivery."
All doctors ordering a C-section must first consult with a nurse and another doctor, he said, which helps promote a workplace culture more supportive of vaginal deliveries.
Dozens of other hospitals maintained strikingly high C-section rates. Doctors at Valley Baptist Medical Center — Brownsville, a for-profit hospital in Brownsville, Texas, delivered over half of the 14,500 babies born at the hospital by C-section between 2018 and 2024, Business Insider's analysis showed. Of those, nearly 3,600 babies were delivered to women who underwent a C-section for the first time.
Experts look to prevent first-time C-sections, since they almost always result in more. At Valley Baptist, 99% of pregnant women with one or more prior C-sections underwent another over the same seven-year period.
Some hospitals treat women with high-risk pregnancies and may have a higher overall or first-time C-section rate to best protect the lives and safety of those women and their newborns. To better evaluate a hospital's potential for performing medically unnecessary C-sections, experts and federal health agencies look at the rate doctors perform C-sections on women with low-risk pregnancies, since they're the least likely to require surgery to safely deliver their babies.
Women with low-risk pregnancies may still be obese, be older, or have other complications, such as preeclampsia, which may mean delivering their babies by C-section is safest. Still, dozens of experts told Business Insider that low-risk pregnancies are the most useful metric for evaluating the quality of a hospital's maternal care.
At Valley Baptist, doctors performed C-sections on half of all women with low-risk pregnancies, on average, over seven years. That's double the low-risk C-section rate of the next closest hospital, less than 5 miles away.
Valley Baptist's spokesperson did not respond to Business Insider's queries by phone and email.
Large swings in low-risk C-section rates underline the dramatic influence a hospital has on women in its care. Controlling for a constellation of factors — hospital obstetric care levels, delivery volume, urban or rural location, maternal age, race, health, and income — multiple studies show one of the biggest risks for undergoing a medically unnecessary C-section is the hospital a woman delivers in.
Our first-of-its-kind map allows users to search hospitals across these regions and makes C-section rates publicly available to compare across nearby hospitals.
'That all goes back to money'
In the American medical system, money dominates care. Most US hospitals operate as "fee-for-service," meaning they bill and garner reimbursements for each service they provide. Each baby they deliver nets reimbursable fees.
A C-section performed by an obstetrician is more highly reimbursed than a vaginal delivery. In 2020, the surgery averaged around $17,000 in insurance reimbursements, compared to just under $11,500 for vaginal birth, according to a 2022 study.
The surgery is also more cost-effective. Hospitals maximize reimbursements from labor by keeping delivery volume high, according to former hospital administrators and recent industry analysis. The more babies delivered, the higher the collective payout.
For hospitals and providers looking to increase delivery efficiency, it's simple math. A vaginal delivery can take days, while a C-section takes less than an hour.
Those indirect incentives appear most acute at for-profit hospitals motivated to deliver higher shareholder returns. Across nearly all states in Business Insider's analysis, surgeons at for-profit hospitals perform C-sections at higher rates, on average, than other hospitals. Overall, for every 1000 women with low-risk pregnancies, around 289 will undergo a C-section at for-profit hospitals, compared with 254 women at all other hospitals — a 14% increase.
Acceptable outcomes, acceptable cost
There are proven, evidence-based strategies for hospitals to safely reduce unnecessary C-sections.
In April 2025, the American College of Obstetricians and Gynecologists recommended that hospitals safely lower low-risk C-section rates by fostering a workplace culture more supportive of vaginal birth. This means hospital leadership commits to standard, evidence-based protocols for common diagnoses that lead to C-sections, like when labor has "failed to progress," or interpreting electronic fetal heart rate monitors, which decades of research show can trigger unnecessary C-sections when misread.
Hospital staffing also matters. C-section rates were 11% lower in hospitals with enough staff to assign at least one nurse to care for every woman in labor, according to one large study. Many hospitals don't employ enough nurses to reach that benchmark. Nurse salaries are among a hospital's most significant costs, making up around 30% of all facility expenditures. Hospitals hoping to trim staff overhead may cut nursing staff first. For-profit hospitals employ markedly fewer nurses for every patient in their care than other hospitals, according to a 2025 study.
In 2020, Newsweek and US News & World Report named Princeton Baptist one of the top maternity hospitals in the country, one of only two hospitals in Alabama to achieve the distinction.
That quality of care didn't balance the cost.
Princeton Baptist saw a 70% increase in the number of babies doctors delivered there between 2018 to 2022. To generate even more revenue, Cooper said she brought in significantly more pregnant women with private insurance to increase reimbursements.
It still wasn't enough. To avoid C-sections, Cooper said, she needed available hospital beds and enough nursing staff to support a woman as she labored for up to three days. That's far more hospital overhead for a vaginal birth that's ultimately less lucrative than a C-section that takes less than an hour.
"There is so much systemic pressure to get more people delivered so you can get the next person in," Cooper said. "And that all goes back to money." Ultimately, the price was too high.
In 2023, Tenet Healthcare, one of the largest for-profit medical systems in the US and then Princeton Baptist's majority owner, closed the hospital's labor and delivery department. Nationwide, more than 500 hospitals have closed their labor and delivery departments since 2010.
Tenet diverted all remaining deliveries to nearby Brookwood Medical Center, a much larger hospital that delivered five times the number of babies as Princeton Baptist each year.
Doctors at Brookwood performed low-risk C-sections at double the rate, on average, as Princeton Baptist, Business Insider's data showed. In 2024, Brookwood doctors operated on nearly one in three women with low-risk pregnancies — among the highest low-risk C-section rates in the state.
David McKinney, the spokesperson for Orlando Health, the parent company of Brookwood and Princeton Baptist as of late 2024, referred Business Insider's questions to Tenet. Multiple Tenet spokespeople did not respond to Business Insider's queries.
In the end, the fight overwhelmed Cooper. Exhausted and burned out, she left the practice in late 2022, less than a year before Princeton Baptist closed the labor and delivery department's doors.
"It's hard to be an outsider in your own field," she said. "It's a hard enough field to be in anyway."
Without intervention, hospital C-section rates almost always rebound to meet the demands of the US medical system, said Dr. Steven L. Clark, an obstetrician at Baylor College of Medicine in Texas, who has studied the US C-section rate over decades.
It's economics, Clark said: "This is the rate which gives the American population acceptable outcomes for acceptable cost."
In most states, hospitals are not required by law to participate in initiatives aimed at safely lowering C-section rates. When left to themselves, hospitals rarely prioritize reducing medically unnecessary cesareans, more than a dozen healthcare providers and two former hospital administrators told Business Insider. Most default to concern for their bottom lines.
But not always.
States including California, Iowa, and New Jersey have successfully supported more vaginal deliveries at hospitals participating in state-led initiatives to improve maternal care.
At the beginning of 2025, dozens of Alabama hospitals volunteered to participate in a state-led initiative to safely lower their collective first-time C-section rate by 20% by 2027. Brookwood, under new management by Orlando Health, is among them. The hospital with the highest low-risk C-section rate in the state is not.
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