Reducing Unnecessary C-Section Births

By New York TImes

You are about to give birth. Pregnancy has gone smoothly. The birth seems as if it will, too. It’s one baby, in the right position, full term, and you’ve never had a cesarean section — in other words, you’re at low risk for complications.

What’s likely to be the biggest influence on whether you will have a C-section?

(A) Your personal wishes.
(B) Your choice of hospital.
(C) Your baby’s weight.
(D) Your baby’s heart rate in labor.
(E) The progress of your labor.

The answer is B. In California, for example, hospitals’ rates for cesarean sections performed in low-risk births range from 11.2 per cent to 68.8 per cent. (pdf) The rest of the factors do influence the decision. But the hospital determines how these factors are treated.

Some hospitals consider very big babies to be automatic C-sections. Some don’t. A pattern on a fetal heart rate monitor might prompt a C-section in one hospital, and a “watch and wait” at another. Doctors’ choices matter, of course, but a hospital can set rules that limit those choices.

“One view is,‘Gosh, this patient’s just not progressing,’” said David Lagrew, an obstetrician who is the chief integration and accountability officer for MemorialCare Health System in Southern California. “’She’s going to have a C-section in a couple of hours anyway, so let’s get it over with. The patient won’t suffer more, and I can go home and I won’t get replaced by someone else.’ Or, you can say, ‘Let’s wait another hour or two.’”

C-sections save lives — when needed. But the enormous variation in rates, with very little variation in outcomes, shows that a great many of them aren’t necessary. In the last 15 years, the rate of C-section has gone up by 50 percent in the United States. According to Jeffrey Ecker, chairman of the American Congress of Obstetricians and Gynecologists’ committee on obstetric practice, that rise “has not been paralleled by any important fall in rates of things like cerebral palsy” — in other words, outcomes that C-sections are often performed to prevent.

C-sections themselves pose some risks to babies, and can create serious complications for mothers, such as hemorrhage, infection and post-partum depression. Having a first baby by C-section leaves a woman with a 90 percent chance that subsequent births will be by C-section as well. And with each C-section, the risk of serious complications rises.

The federal Department of Health and Human Services has set a goal for C-section at 23.9 percent in low-risk births by 2020. “It could be lower, but it’s a starting point,” said Elliott Main, the medical director of the California Maternal Quality Care Collaborative. “Thirty, 40, 50 percent it clearly shouldn’t be.”

It is telling that a recent study found that when the patients are themselves doctors, and presumably better-informed, C-sections are less common.

In 2014, I wrote about San Francisco General Hospital, where the commendable C-section rate in low-risk births (now about 15 percent) can be attributed largely to the fact that doctors work shifts and earn a salary. They’re around no matter what, and they have no financial incentive to do the delivery themselves. So they have much more patience with a woman’s labor.

In hospitals that use fee-for-service billing, however, the bulk of an obstetrician’s pay comes from performing the actual delivery, so doctors want to do their own. This leads to a reluctance to wait.

The vast majority of hospitals are still fee-for-service. Are there measures these hospitals can take to lower their C-section rates?

We now know the answer is yes.

In 2014, the Pacific Business Group on Health, an alliance of businesses that are large buyers of health care for their employees, began a pilot program to reduce C-sections at three hospitals in the Los Angeles area: Hoag Hospital in Newport Beach and two MemorialCare hospitals, in Long Beach and Laguna Hills. All brought their rates down by 20 percent (pdf). And there they have stayed. None of the hospitals had any increase in complications.

The pilot program was prompted by three developments:

Increasing medical concern

“The U.S. suddenly got into crazy range — high 30s to 50 percent,” says Lagrew. “We’ve begun to see the complications in subsequent pregnancies — the placental complications and near-death or death caused from surgery done two to three years prior. That’s the ‘aha!’ moment now driving the impetus to lower it back down.”

Resistance to high costs

C-sections can cost 50 percent more than vaginal births, and are more lucrative for doctors and hospitals. This provides incentive for them to do more cesareans.

Also, there are post-operative costs: readmissions, home care and the high likelihood that subsequent births will also be by C-section, plus the costs and lost work time of having to recover from major surgery.

Kim Mikes, operations director of the Women’s Health Institute at Hoag, said that from conversations with the Pacific Business Group on Health, “we knew they were starting to look at an organization’s rates, and we knew it was going to be a determinant of who would be contracted with and who wouldn’t.” Benefits managers from local corporations also started raising concerns with different hospitals.

“We started talking about how we could try to raise awareness of these issues and get those numbers down,” Mikes said, adding that the hospital told physicians: “This is not a matter of convenience. It’s going to end up impacting us financially, and the health of our patients.”
The rise of data

California has unusually good data on C-section rates. That’s due to the Maternal Data Center, run by the California Maternal Quality Care Collaborative, which has managed numerous quality improvement projects, and helped with this one. The database merges information from hospital discharge records with birth certificate data. Data on a hospital’s rates of C-section are public. But hospitals that provide the raw information can also use the database to look at individual doctors and track procedures, to find the problems that lead to more C-sections.

And here’s how the hospitals lowered their C-section rates:

Data helped to overcome resistance from doctors.

“In academic circles there is consensus at a population level that C-section rates are too high,” said Ecker. “But many of those same doctors would say: ‘The way I practice is right and good.’ Translating ‘The rate is too high’ into which patients are not to get a C-section delivery is much more difficult.”

Main said: “Physicians in private practice don’t want anybody telling them what to do. Hospital administrations can say: ‘Let doctors be doctors. Whatever they do is their business.’ We see that in a lot of small and medium hospitals.”

But the data was persuasive.

“In other hospitals, physicians don’t have access to data on their C-section rate,” said Brynn Rubinstein, senior manager of Pacific Business Group on Health’s Transform Maternity Care project. “They’ll remember their last ten, but they don’t really have actual data in hand and they’re not being compared to other physicians in their hospital. Having access to this to drill down is really powerful. It gave physicians an idea of where they really stood outside the norm, which was hugely important for clinician buy-in.”

At first, doctors saw only their own data. Hoag then released the data to all doctors, and suddenly everyone knew how everyone was doing. That’s when C-section rates took a big drop. “No one likes to be the outlier,” said Main.

Now hospitals are slicing the data thinner — for example, to look at how often individual doctors induced labor in patients whose cervix was insufficiently dilated, a step that often leads to C-section. “We’re about to get a new bump downward,” said Lagrew.

Adminstrative shifts made C-sections less automatic.

At Hoag, doctors used to be able to easily schedule C-sections, no approval needed. The hospital made it more cumbersome. Now they must indicate whether the reason is medical or elective, and the request must be approved by a division chief and a laborist — an in-hospital doctor who handles deliveries.

The hospital also requires patients in the low-risk category to read a brochure about C-section titled “Understanding the Risks.”

New protocols promoted patience during labor.

MemorialCare now discourages inducing labor until the cervix has reached a point where labor is likely to be short and successful. The hospital created uniform terminology for fetal heart rate patterns, and standards for how to respond.

Lagrew believes that having guidelines may protect doctors against another driver of C-sections: the malpractice lawsuit. Some research has found that the real effect of this pressure on C-section rates is small. But it is nonetheless an important concern. Rubinstein said that one hospital backed out of the study because of malpractice concerns.

“The worry is still there, but it’s mitigated if I’m following a standard protocol and using best practice,” said Lagrew.

Nurses and laborists took an increased role.

Mikes, who is a nurse herself, said of her colleagues: “A lot has to do with support they provide, how confident they help patients feel about their ability to deliver, how active they keep patients in the early stages.” Hoag began giving bonuses and merit raises to nurses who were supportive and active with patients — “the ones not hanging around the desk,” as she put it.

Doctors don’t monitor labor. Nurses and hospitalists do. “When the nurse is on phone to the doctor, it’s important how they present it,” Mikes said. “It can be: ‘She’s not moving that fast,’ or ‘She’s not moving as fast as I had hoped but I’m trying this and this.’”

MemorialCare’s Saddleback hospital amplified the role of hospitalists. They watch labor and do deliveries — with the delivery fee still going to the absent doctor, which allows the doctor to go home without doing a preemptive C-section.

New rates cut the perverse incentives to do C-sections.

Each hospital negotiated with one or two of its insurers to pay a uniform rate for childbirth, vaginal or not. The negotiations took a long time, and the new payment schemes didn’t kick in until months after the hospitals dropped their C-section rates. And since only a few insurers were involved, only 10 percent to 20 percent of births were covered. Nevertheless, the payment reform may have been very influential, because people knew it was coming — indeed, this small step is likely a glimpse of the future — and it was a constant topic in hospital meetings.

The California HealthCare Foundation now plans to help at least 60 hospitals — a quarter of all those in the state — to start the program this year. It has also provided funding for the Maternal Quality Care Collaborative to create a toolkit; once a hospital has used data to pinpoint the drivers of a high C-section rate, the toolkit will suggest attack strategies.

The foundation plans to work with large employers to bring their concerns about unnecessary C-sections to the hospitals they use. “Even if you’re not on board, you have to start paying attention,” said Stephanie Teleki, senior program officer for high-value care at the foundation.

Spreading the program may be much more difficult than it was to pilot. Hoag and MemorialCare signed on precisely because their leaders are dedicated to bringing down C-section rates; Lagrew, for instance, has been working on the problem since the 1980s. That commitment is a key to reducing unnecessary C-sections and to maintaining that reduction. “To sustain the change you have to bake it into the system,” said Lagrew. “So physicians don’t go back to, ‘It’s the holiday weekend and I want to go home.’”

To view the original New York Times article, please click here.