California is preparing to launch an ambitious plan to reduce C-sections rates. If successful, that reduction will save taxpayer money and keep both mothers and babies healthier.
Kicking off in early 2016, the plan funded by the Oakland-based California HealthCare Foundation is meant to financially reward hospitals for vaginal births and reduce the pressure on doctors and laboring mothers to deliver quickly.
Last year, amid increasing attention to maternal care by health advocates, CHCF released an alarming report. A healthy pregnant woman’s chances of giving birth by C-section are uncomfortably dependent upon where she delivers her baby.
Overall, just over 27 percent of healthy women in California deliver their babies by C-section. But at hospitals labeled “high-performing” by CHCF, a healthy woman will have less than 20 percent chance of C-section. Conversely, at a low-performing hospital, that risk is greater than 50 percent.
That’s a problem because C-sections are major surgeries that carry risks of infection, uncontrolled bleeding, blood transfusions, blood clots, and postpartum depression. They’re also correlated with a lower breastfeeding rate, which is detrimental both to mother and baby.
It doesn’t have to be this way. Other developed countries have far lower C-section rates. Only about one in five —or 20 percent—of Finnish, French and Swedish babies are born this way.
Earlier this year the World Health Organization released a statement saying the “ideal rate” for C-sections is between 10 and 15 percent, about half the average rate in California. While C-sections can save lives both for mothers and babies, that’s only true up to a point. The WHO says globally the number of maternal and newborn deaths go down as C-section rates rise towards 10 percent. After that, there is no improvement.
Beyond being risky, C-sections — the most commonly performed surgery in the U.S. — are expensive, about $15,000-$20,000 per birth. Both nationally and in California, Medicaid pays for roughly half of all births.
Policymakers see lowering the C-section rates as wins both for patient health and state coffers. The U.S. government has set a national target of 23.9 percent as part of its Healthy People 2020 goals. To meet that benchmark, 60 percent of California hospitals need to reduce their C-section rates.
One route: Using Nurse Midwives
If any woman has tried hard to have a vaginal birth, it has been Edwina Brown. Brown moved to California from the U.K. with her husband last year. The couple was expecting their first child, who was born last September.
For several months she saw an obstetrician. She chose to switch to nurse midwives. The preference was partially cultural, she says. In her native England midwives attend 80 percent of all births. In the U.S. they are present for just 8 percent.
“At the obstetrician’s I felt that there was less room for questions and discussion about the testing they were doing, and how the birth would be,” says Brown from her home in Petaluma, cradling Lily in her arms.
“With the midwives, I felt it was much more supportive. They wanted to listen and understand what you wanted and—while keeping baby and mum safe—find a way to respect your wishes.”
How One Hospital Brought Its C-Section Rate Down In A Hurry
Brown delivered at Marin General Hospital, where, several years ago, the hospital changed staffing protocols in an effort to reduce C-sections. (The change was independent of any direction from CHCF.)
Years of data had shown two populations of women within in the hospital consistently maintained significantly different C-section rates. Privately insured women averaged 32 percent, while publicly insured women averaged only 16. A similar discrepancy is seen in many other hospitals.
Nurse midwives provided most of the care for publicly-insured women. A 24-hour laborist — a doctor who specializes in delivering babies — was always on hand to operate or give assistance if needed. Privately insured women followed the more traditional U.S model. Their private physicians would leave busy practices and lives to deliver at the hospital when the baby was expected.
In 2011 the hospital revamped its staffing so that all expecting mothers would have access to 24-hour midwives and a 24-hour laborist. The change caught the attention of Melissa Rosenstein with UC, San Francisco’s Center for Reproductive Science.
“Laborists are becoming more popular, but there isn’t a ton of data on what the outcomes are,” she says. “And it’s the same with midwives. There is plenty of data about how safe and effective midwifery is, but not as much as research on what the effect is on cesarean delivery rates, so we thought this would be an excellent natural experiment since this practice change was going to happen.”
In a study published last September in Obstetrics & Gynecology, Rosenstein and her colleagues reported a significant drop in privately insured women’s C-section rates — from 31.7 to 25 percent — between 2011 and 2014.
“It was our working hypothesis that we would see a decrease,” she says, “but it was more dramatic than we expected.”
Though every C-section seems necessary in the moment, Rosenstein says, “the truth is there are very few indications that a woman really needs one, there is usually a little wiggle room.” If physicians work on labor and delivery exclusively, then they can be “a little bit more patient,” she added, and wait for a vaginal delivery.
Sherri Matteo, one of the certified nurse midwives at Marin General Hospital, says women and doctors don’t always know what women are capable of.
“Even when they think, ‘Oh! You’re going to have a 12-pound baby? You can’t possibly have this baby vaginally.’ I can tell you from experience that some women can. Until you allow a trial of labor, and allow a woman’s body to do what it’s supposed to do, we don’t know for sure.”
There are clear exceptions. When a baby is in a breech position — when the bottom or feet, rather than the head, will be the first to come out — is not supported for vaginal delivery by most U.S. doctors and hospitals.
That’s what happened to Brown’s baby and she was desperate for the baby to turn head down.
“I didn’t want a cesarean but I knew it was a possibility from week 32,” she says. Brown had bad dreams about waking up on an operating table, but says her relationship with hospital staff helped allay her anxiety. In the end she did have a C-section — efforts to manually turn Lily in the hospital prior to delivery weren’t successful — but she feels the birth was a better experience than it would have been if led by a physician.
“I felt so supported the entire time,” Brown says.
Carrots and Sticks
Hospitals don’t have to embrace the nurse midwife model to reduce their C-section rates, however. In fact, with so few midwives and midwife training programs in California, there would not be enough to meet the needs of the state, says Stephanie Teleki, who is overseeing the CHCF effort to reduce c-sections.
“You need to pull a lot of different levers to make these changes,” she says. “Nurse midwives could be part of the long-term solution, but in the short-term we’ll need to be creative about how to get this done.”
In California, Where You Deliver Your Baby Matters
Hoag Memorial Hospital Presbyterian in Orange County, under pressure from large employers and groups like the Pacific Business Group on Health, reduced C-section rates by 20 percent over 15 months through a suite of measures, some carrots, some sticks. Administrators shared the C-section rates of individual doctors. Large insurance buyers like Disney and Blue Shield altered payments so that hospitals didn’t earn more from elective C-sections than from vaginal births. And nurses received end-of-the-year bonuses if they helped the hospital reach its goals. Hoag became a test case for measures that will be taken around the state, under the CHCF’s initiative.
One key aspect of the CHCF’s plan is to fund a “toolkit,” prepared by the California Maternal Quality Care Collaborative, a nonprofit group comprised of several dozen public and private agencies and funded by CHCF and the Centers for Disease Control, among others. It’s due out in March 2016. The California HealthCare Foundation is also funding medical professionals to assist about 60 hospitals in implementing the guidelines.
Teleki says they’re particularly interested in reaching hospitals in Los Angeles, San Diego and Orange counties. “(T)hat is where the birth rate is the highest and C-section rates are also very high,” she says. “If we double down in some of those markets it’s a real opportunity to not only impact those areas but to move the needle statewide.”
In what will perhaps be the most impactful step, the foundation plans to work with groups of health care purchasers to make C-sections less profitable.
This could mean the wider use of “bundled payments,” where hospitals are paid a per-birth rate, instead of being paid a higher rate for C-sections, as they are now. At a flat rate, hospitals should preferentially slant toward vaginal births.
Ultimately, says Teleki, it will be critical to financially reward providers for promoting vaginal birth.
“There might be some do-gooders right now,” she says. “But if hospitals earn more money to do C-sections, it’s hard to then say, ‘Now please lower your c-sections.'”
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