Neighboring hospitals have drastically different C-section rates. Financial pressures help explain why.

"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."

Hiring a nurse-midwife at Princeton Baptist enabled clinicians to support many more vaginal births and dramatically reduce C-section rates. Between 2018 and 2023, doctors at the hospital performed C-sections on fewer than one in six low-risk women, roughly half Alabama's average and far below other Birmingham hospitals. The shift required prolonged battles for staffing, time, labor beds, and cultural change against a system that financially rewards surgical deliveries. C-sections remain vital when necessary but are frequently overused in the US, occurring at roughly twice the World Health Organization's recommended rate and far above rates in Nordic countries.

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