Rachel Bruns is a volunteer advocate for quality maternal health care in Iowa.

I recently recounted how it took the Iowa Department of Public Health (IDPH) 170 days to respond to my request for information on the total births, primary cesareans, total cesareans, and vaginal births after cesareans (VBACs) at Iowa hospitals. I eventually received aggregated five-year totals (2016 through 2020) for each birthing hospital in Iowa.

The International Cesarean Awareness Network (ICAN) of Central Iowa, where I serve as a volunteer chapter leader, has made the data available on our website. You can see it in table form below as Appendix 1. 

While I would have preferred for IDPH to provide the figures for a single year, as I requested, the compiled data still tells us a lot about the overuse of cesareans at several Iowa hospitals and the lack of VBAC access across much of the state.

Erin Flage, a former ICAN chapter leader from the Cedar Falls/Waterloo area, took the time to analyze the data to give us more insights: which hospitals have cesarean rates that raise concerns, which hospitals have comparatively low cesarean rates, and which hospitals have the highest VBAC rates. Erin’s analysis includes a top five for each area below.

IDPH provided the facility name, total births, cesarean, primary cesarean, and VBAC data. Erin then calculated the VBAC rate, based on the VBAC deliveries resulting in live births divided by the sum of VBACs and repeat cesareans. (See more on the VBAC calculation method from the March of Dimes.) Erin also added information such as the county where the hospital is located, whether it is a Level I, II, or III facility, and noted when data was merged for hospitals that were renamed, as IDPH had listed those facilities separately.

The CDC’s Office of Disease Prevention and Health Promotion set a “Healthy People” goal for 2020 to reduce cesarean births among low-risk women with no prior births (primary cesareans) from the baseline average in the United States of 27.4 percent in 2007 to 24.7 percent, and reduce cesarean births among low-risk women giving birth with a prior cesarean from the baseline of 90.8 percent in 2007 to 81.7 percent.

While some Iowa hospitals are meeting the Healthy People 2020 goal, several are not. Iowa as a whole has met the goal for low-risk women with no prior cesarean (averaging around 21 percent), but is falling short on reducing cesarean births for low-risk birthing people with a prior cesarean, which speaks to the experience of many Iowans struggling to find VBAC supportive care.

For some important context, the 2019 guidelines on VBAC from the American College of Obstetrics and Gynecology (ACOG) state, “available data confirms that TOLAC [trial of labor after cesarean] may be safely attempted in both university and community hospitals and in facilities with or without residency programs.”

ACOG also reaffirmed what they said in their 2010 guidelines: “Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.” All Level I, II, and III hospitals in Iowa have facilities capable of performing emergency deliveries.

The ACOG guidelines are crystal clear: “After counseling, the ultimate decision to undergo TOLAC or repeat cesarean delivery should be made by the patient in consultation with her obstetrician or other obstetric care provider.” The provider advises. The patient decides. ACOG also states that suspecting a big baby, going beyond 40 weeks, having a short birth interval, having a low vertical or unknown scar, expecting twins or having a high body mass index are not reasons to preclude offering VBAC.

In addition, the guidelines affirm that induction, augmentation, epidural, and a procedure designed to rotate a fetus from a breech position remain options during planned VBAC. To learn more about the challenges faced by birthing people in Iowa around VBAC access and the overuse of cesareans in Iowa, read my article from last year on that subject. 

At the end of the day, there are risks and benefits to both cesareans and VBAC/vaginal birth. Birthing people should be counseled accordingly and be able to select the best option for their unique circumstances. Unfortunately, for most birthing people with a prior cesarean, it is challenging to find supportive care that is following these guidelines and evidence based practices. 

I think the data speaks for itself. If I were planning to have a baby again, I would pay close attention to the primary and total cesarean rate and get further information about providers’ individual rates. Several hospitals have alarming cesarean rates. 

Some good news emerged last year: 43 of Iowa’s current 57 birthing hospitals are participating in the Alliance for Innovation on Maternal Health safety bundle on the “safe reduction of primary cesarean,” made possible by a $10 million federal Health Resources and Services Administration grant. The participating hospitals represent 93 percent of Iowa births, and similar initiatives in other states have lowered cesarean rates.

IDPH has not provided a public list of which hospitals are participating in this program. Another question pregnant Iowans can ask their provider is whether the hospital where they would deliver is participating in the safety bundle.

The safety bundle started in May 2021, so we hope to learn soon whether Iowa’s cesarean rates improved in 2021 and 2021 as a result.

Top Five Hospitals By Total Births

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level III	Polk	MercyOne Des Moines Medical Center	20,345	6,869	3,990	367	34%	23%	11%	Renamed from Mercy Medical Center-Des Moines
Level III	Polk	UnityPoint Health-Iowa Methodist Medical Center-Des Moines	19,134	6,237	3,683	370	33%	23%	13%
Level III	Johnson	University of Iowa Hospitals & Clinics	12,030	4,242	2,553	752	35%	27%	31%
Level II Regional Neonatal Center	Linn	UnityPoint Health-St. Luke’s Hospital-Cedar Rapids	11,812	3,760	2,259	271	32%	23%	15%	Renamed from UnityPoint Health-St. Luke’s Hosp.-Cedar Rapids
Level II Regional Center	Woodbury	UnityPoint Health-St. Luke’s Hospital-Sioux City	10,055	3,087	1,520	183	31%	18%	10%

Top Five Hospitals by Highest Total Cesareans

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level II Regional Center	Cerro Gordo	MercyOne North Iowa Medical Center	4,314	1,663	907	7	39%	26%	1%	Renamed from Mercy Medical Center-North Iowa-Mason City
Level I	Wright	Iowa Specialty Hospital-Clarion	2,002	759	395	30	38%	25%	8%
Level I	Boone	Boone County Hospital	653	245	139	1	38%	25%	1%
Level I	Poweshiek	Grinnell Regional Medical Center-Grinnell	808	302	171	0	37%	25%	0%
Level I	Sioux	Orange City Area Health System	1,111	395	234	1	36%	25%	1%

Top Five Hospitals by Lowest Total Cesarean Rate

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level II	Johnson	Mercy Iowa City	5,650	988	570	344	17%	12%	45%
Level I	Winneshiek	Winneshiek Medical Center-Decorah	1,262	275	173	3	22%	15%	3%
Level II Regional Center	Black Hawk	MercyOne Waterloo Medical Center	5,849	1,307	710	260	22%	14%	30%	Renamed from Covenant Medical Center-Waterloo
Level I	Polk	Broadlawns Medical Center-Des Moines	2,191	496	247	37	23%	13%	13%
Level II	Black Hawk	UnityPoint Health-Allen Hospital-Waterloo	5,714	1,298	852	133	23%	17%	23%

Top Five Hospitals by Highest Primary Cesarean Rate

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level III	Johnson	University of Iowa Hospitals & Clinics	12,030	4,242	2,553	752	35%	27%	31%
Level II Regional Center	Cerro Gordo	MercyOne North Iowa Medical Center	4,314	1,663	907	7	39%	26%	1%	Renamed from Mercy Medical Center-North Iowa-Mason City
Level I	Boone	Boone County Hospital	653	245	139	1	38%	25%	1%
Level I	Poweshiek	Grinnell Regional Medical Center-Grinnell	808	302	171	0	37%	25%	0%
Level I	Sioux	Orange City Area Health System	1,111	395	234	1	36%	25%	1%

Top Five Hospitals by Lowest Primary Cesarean Rate

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level II	Johnson	Mercy Iowa City	5,650	988	570	344	17%	12%	45%
Level I	Howard	Regional Health Services of Howard County-Cresco	268	68	28	1	25%	12%	2%
Level I	Buena Vista	Buena Vista Regional Medical Center-Storm Lake	1,670	410	174	34	25%	12%	13%
Level I	Polk	Broadlawns Medical Center-Des Moines	2,191	496	247	37	23%	13%	13%
Level I	Allamakee	Veterans Memorial Hospital-Waukon	582	134	67	4	23%	13%	6%

Top Five Hospitals by Lowest VBAC Rate (where VBAC >1)

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level II	Pottawattamie	Jennie Edmundson Hospital-Council Bluffs	2,658	856	490	2	32%	21%	1%
Level I	Polk	UnityPoint Health-Methodist West Hospital-West Des Moines	5,277	1,665	1,037	4	32%	22%	1%
Level II Regional Center	Cerro Gordo	MercyOne North Iowa Medical Center	4,314	1,663	907	7	39%	26%	1%	Renamed from Mercy Medical Center-North Iowa-Mason City
Levell II	Des Moines	Great River Medical Center-West Burlington	2,717	779	513	3	29%	21%	1%
Level II	Wapello	Ottumwa Regional Health Center	2,240	695	395	5	31%	20%	2%

Hospitals with a Total < State Avg (29.6), Primary < State Avg (20.1), VBAC > State Avg (16.3)

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level II	Johnson	Mercy Iowa City	5,650	988	570	344	17%	12%	45%
Level III	Johnson	University of Iowa Hospitals & Clinics	12,030	4,242	2,553	752	35%	27%	31%
Level II Regional Center	Black Hawk	MercyOne Waterloo Medical Center	5,849	1,307	710	260	22%	14%	30%	Renamed from Covenant Medical Center-Waterloo
Level I	O’Brien	Sanford Medical Center Sheldon	631	161	93	24	26%	17%	26%
Level II Regional Neonatal Center	Scott	Genesis Medical Center-East Davenport	9,496	2,276	1,356	288	24%	16%	24%

Polk/Story County Hospitals

Level	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level I	Polk	Broadlawns Medical Center-Des Moines	2,191	496	247	37	23%	13%	13%
Level III	Polk	MercyOne Des Moines Medical Center	20,345	6,869	3,990	367	34%	23%	11%
Level III	Polk	UnityPoint Health-Iowa Methodist Medical Center-Des Moines	19,134	6,237	3,683	370	33%	23%	13%
Level I	Polk	UnityPoint Health-Methodist West Hospital-West Des Moines	5,277	1,665	1,037	4	32%	22%	1%
Level II	Story	Mary Greeley Medical Center-Ames	6,005	1,531	957	54	25%	18%	9%

Appendix 1: 

Data Set Used for Analysis

Level	Status	County	Facility	Total Births	Total Cesareans	Total Primary Cesarean	Total VBAC	Total Cesarean Rate	Primary Cesarean Rate	VBAC Rate	Notes
Level I	Open	Boone	Boone County Hospital	653	245	139	1	38%	25%	1%
Level I	Open	Polk	Broadlawns Medical Center-Des Moines	2,191	496	247	37	23%	13%	13%
Level I	Open	Buena Vista	Buena Vista Regional Medical Center-Storm Lake	1,670	410	174	34	25%	12%	13%
Level I	Open	Cass	Cass County Memorial Hospital-Atlantic	578	178	85	3	31%	18%	3%
Level I	Open	Cherokee	Cherokee Regional Medical Center	555	153	78	1	28%	16%	1%
Level I	Open	Pottawattamie	CHI Health Mercy Council Bluffs	1,845	442	298	4	24%	18%	3%
Level I	Open	Crawford	Crawford County Memorial Hospital-Denison	631	207	136	2	33%	24%	3%
Level I	Open	Floyd	Floyd County Medical Center-Charles City	389	118	59	2	30%	18%	3%
Level I	Open	Plymouth	Floyd Valley Hospital-Le Mars	478	130	74	3	27%	18%	5%
Level I	Open	Lee	Fort Madison Community Hospital	1,644	466	244	1	28%	17%	0%
Level II Regional Neonatal Center	Open	Scott	Genesis Medical Center-East Davenport	9,496	2,276	1,356	288	24%	16%	24%
Levell II	Open	Des Moines	Great River Medical Center-West Burlington	2,717	779	513	3	29%	21%	1%
Level I	Open	Union	Greater Regional Medical Center-Creston	875	229	167	0	26%	21%	0%
Level I	Open	Poweshiek	Grinnell Regional Medical Center-Grinnell	808	302	171	0	37%	25%	0%
Level I	Open	Wright	Iowa Specialty Hospital-Clarion	2,002	759	395	30	38%	25%	8%
Level II	Open	Pottawattamie	Jennie Edmundson Hospital-Council Bluffs	2,658	856	490	2	32%	21%	1%
Level I	Open	Kossuth	Kossuth Regional Health Center-Algona	636	211	128	0	33%	23%	0%
Level I	Open	Dickinson	Lakes Regional Healthcare-Spirit Lake	864	282	183	0	33%	24%	0%
Level I	Open	Mahaska	Mahaska Health Partnership-Oskaloosa	875	233	105	0	27%	14%	0%
Level II	Open	Story	Mary Greeley Medical Center-Ames	6,005	1,531	957	54	25%	18%	9%
Level II	Open	Johnson	Mercy Iowa City	5,650	988	570	344	17%	12%	45%
Level II	Open	Linn	Mercy Medical Center-Cedar Rapids	4,043	1,216	794	73	30%	22%	15%
Level II	Open	Clinton	MercyOne Clinton Medical Center	1,752	439	307	0	25%	19%	0%	Renamed from Mercy Medical Center-Clinton
Level III	Open	Polk	MercyOne Des Moines Medical Center	20,345	6,869	3,990	367	34%	23%	11%	Renamed from Mercy Medical Center-Des Moines
Level II	Open	Dubuque	MercyOne Dubuque Medical Center	3,794	1,148	663	51	30%	20%	10%	Renamed from Mercy Medical Center-Dubuque
Level II Regional Center	Open	Cerro Gordo	MercyOne North Iowa Medical Center	4,314	1,663	907	7	39%	26%	1%	Renamed from Mercy Medical Center-North Iowa-Mason City
Level II Regional Center	Open	Black Hawk	MercyOne Waterloo Medical Center	5,849	1,307	710	260	22%	14%	30%	Renamed from Covenant Medical Center-Waterloo
Level I	Open	Shelby	Myrtue Medical Center-Harlan	326	102	53	2	31%	19%	4%
Level I	Open	Sioux	Orange City Area Health System	1,111	395	234	1	36%	25%	1%
Level II	Open	Wapello	Ottumwa Regional Health Center	2,240	695	395	5	31%	20%	2%
Level I	Open	Fayette	Gundersen Palmer Lutheran Hospital and Clinics	421	110	52	2	26%	14%	3%	Renamed from Palmer Lutheran Health Center-West Union
Level I	Open	Palo Alto	Palo Alto County Health System-Emmetsburg	411	143	67	1	35%	20%	1%
Level I	Open	Marion	Pella Regional Health Center	2,781	953	561	0	34%	23%	0%
Level I	Open	Howard	Regional Health Services of Howard County-Cresco	268	68	28	1	25%	12%	2%
Level I	Open	Delaware	Regional Medical Center-Manchester	953	315	208	1	33%	25%	1%
Level I	Open	O’Brien	Sanford Medical Center Sheldon	631	161	93	24	26%	17%	26%
Level I	Open	Page	Shenandoah Medical Center	519	124	66	1	24%	14%	2%
Level I	Open	Sioux	Sioux Center Health	894	208	140	0	23%	17%	0%
Level I	Open	Jasper	Skiff Medical Center-Newton	806	276	147	5	34%	22%	4%
Level I	Open	Clay	Spencer Hospital	1,283	330	168	37	26%	15%	19%
Level I	Open	Carroll	St. Anthony Regional Hospital-Carroll	1,774	567	292	21	32%	20%	7%
Level I	Open	Calhoun	Stewart Memorial Community Hospital-Lake City	437	142	81	0	32%	22%	0%
Level II	Open	Black Hawk	UnityPoint Health-Allen Hospital-Waterloo	5,714	1,298	852	133	23%	17%	23%
Level II	Open	Dubuque	UnityPoint Health-Finley Hospital-Dubuque	3,426	892	495	103	26%	17%	21%
Level III	Open	Polk	UnityPoint Health-Iowa Methodist Medical Center-Des Moines	19,134	6,237	3,683	370	33%	23%	13%
Level I	Open	Polk	UnityPoint Health-Methodist West Hospital-West Des Moines	5,277	1,665	1,037	4	32%	22%	1%
Level II Regional Neonatal Center	Open	Linn	UnityPoint Health-St. Luke’s Hospital-Cedar Rapids	11,812	3,760	2,259	271	32%	23%	15%	Renamed from UnityPoint Health-St. Luke’s Hosp.-Cedar Rapids
Level II Regional Center	Open	Woodbury	UnityPoint Health-St. Luke’s Hospital-Sioux City	10,055	3,087	1,520	183	31%	18%	10%
Level II	Open	Scott	UnityPoint Health-Trinity Bettendorf	4,691	1,640	888	83	35%	23%	10%
Level II	Open	Webster	UnityPoint Health-Trinity Regional Medical Center-Fort Dodge	2,436	760	418	58	31%	21%	15%
Level III	Open	Johnson	University of Iowa Hospitals & Clinics	12,030	4,242	2,553	752	35%	27%	31%
Level I	Open	Allamakee	Veterans Memorial Hospital-Waukon	582	134	67	4	23%	13%	6%
Level I	Open	Bremer	Waverly Health Center	1,219	365	202	17	30%	19%	9%
Level I	Open	Wayne	Wayne County Hospital-Corydon	835	223	123	0	27%	17%	0%
Level I	Open	Winneshiek	Winneshiek Medical Center-Decorah	1,262	275	173	3	22%	15%	3%

Top photo of MercyOne North Iowa Medical Center in Mason City originally published on the facility’s Facebook page. The hospital had Iowa’s highest cesarean rate from 2016 through 2020.