Over the past five decades, the rate of C-section deliveries in the United States has increased sevenfold, from 4.5 percent in 1965 to a jaw-dropping 32.9 percent in 2009. By 2014, the rate had decreased slightly to 32.2 percent; nonetheless, C-sections still account for nearly one in three U.S. births. In some parts of the country, the rate of C-section deliveries is nearly 70 percent.
Even more concerning than the sheer numbers of surgical deliveries is the fact that the increase has not been accompanied by improved outcomes for mothers or their infants. According to Jeffrey Ecker, chairman of the American Congress of Obstetricians and Gynecologists’ committee on obstetric practice, the dramatic rise in cesarean sections, “has not been paralleled by any important fall in rates of things like cerebral palsy” or other complications associated with fetal injury during birth.
In a low-risk pregnancy, the decision to perform a surgical delivery is almost entirely driven by physician preference and the protocols of the hospital in which the woman is giving birth. At San Francisco General Hospital, where the C-section rate is about 15 percent, doctors rotate through 24-hour shifts and receive a salary, so there is no financial incentive for a physician to hasten a birth. She is paid the same amount of money whether she is present at the delivery or not.
Conversely, at fee-for-service hospitals, doctors typically are paid more if they are present at the delivery itself. So when labor doesn’t progress as planned, the thought process goes something like this, “Gosh, this patient’s just not progressing. She’s going to have a C-section in a couple of hours anyway, so let’s get it over with,” said obstetrician David David Lagrew, M.D., in an interview with The N.Y. Times. By delivering the baby surgically, the physician gets to go home at a convenient time and “won’t get replaced by someone else.”
C-section births are also more lucrative for hospitals, costing on average 50 percent more than vaginal births. Additionally, women who deliver via C-section are virtually guaranteed to require a C-section for all subsequent deliveries.
A C-section is not an innocuous procedure. Potential short-term harms to the mother include infection, bleeding, blood clots, postpartum depression and death. Long-term sequelae include chronic pelvic pain and an increased risk of ectopic pregnancy, uterine rupture and disorders of the placenta, such as placenta previa and placental abruption. Children born via C-section have a greater risk of respiratory distress and hospitalization in the neonatal ICU as well as a higher incidence of childhood-onset Type I diabetes, allergies and asthma.
In 2012, the U.S. Department of Health and Human Services set a target rate of 23.9 percent for C-section births nationwide. However, according to data from the Leapfrog Group, less than 40 percent of hospitals had met that goal as of 2015.
But at a few hospitals in Southern California, a pilot program is helping physicians close that gap. With urging from the Pacific Business Group on Health, a consortium of businesses that buy health care for their employees, and data from California’s Maternal Data Center, the three hospitals -- Hoag Hospital in Newport Beach and MemorialCare hospitals in Laguna Hills and Long Beach -- have decreased their rates of C-section births by 20 percent.
Here’s a look at what they did.
First, the hospitals began sharing data on physician C-section rates, first with individual physicians and then with the entire physician group. This helped doctors see not only their own rate of C-sections over time, but let them compare themselves to other doctors. According to Brynn Rubinstein, senior manager of Pacific Business Group on Health’s Transform Maternity Care project, “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 Hoag hospital in Newport Beach, physicians soon will have access to even more data, such as how often they performed a C-section after inducing labor when the cervix was not sufficiently dilated -- a big influencer of C-section births.
Another factor that influenced the rate of C-sections at the pilot hospitals was a shift in hospital protocols. At Hoag Hospital in Newport Beach, for example, doctors historically were allowed to decide whether to perform a C-section independently, without input from hospital staff. Now they must indicate in writing the reason for the procedure and have it approved by both a division chief and a “laborist” — a doctor on the hospital staff who handles deliveries.
At MemorialCare’s two participating hospitals, written standards now exist around when to induce labor (e.g. discouraging induction when the cervix is not sufficiently dilated.) Hospital officials have also developed uniform terminology for fetal heart rate patterns and standards of care around how to respond. The hospitals have also begun allowing laborists to monitor and perform deliveries for community obstetricians, who still receive their full fee.
The three hospitals have also worked to increase the involvement of nurses in the birthing process; Hoag is even and providing bonuses and incentives to those who are most active in patient care. Interventions to help labor progress more naturally, such as encouraging birthing women to remain upright and active during the early stages of labor, are being encouraged, and nurses are being trained to communicate with physicians in different ways. As Kim Mikes, operations director of the Women’s Health Institute at Hoag, explains, “It’s important how they present it. 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.”
The final initiative of the pilot program was negotiating with insurers to pay the same rate for C-section and vaginal deliveries, a process that took a long time and faced many roadblocks. Only a fraction of deliveries were actually covered by the new reimbursement scheme, but those involved believe it had a significant effect.
Based on the success of the pilot program, the The California HealthCare Foundation is currently putting together a plan to assist an additional 60 hospitals in California to implement the program in 2016.
More healthcare data and new financial models are having an ever-increasing influence on physician practice across the United States, and keeping up with changing standards is a daunting task. Nonetheless, doing so is critical to providing the best care for your patients and maintaining your own financial health.
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