Women in California with low-risk deliveries having their first babies have between a 12 percent and 70 percent chance of delivering by cesarean section. But where they fall on that spectrum depends less on medical necessity than on where they deliver their baby.
“The big driver here is the huge variation in care. It really boils down to local culture on the labor and delivery unit,” said Elliott Main, an OB GYN and Medical Director of the California Maternal Quality Care Collaborative. That’s a group of state agencies, professional groups, health systems, foundations and health plans working on maternal health issues.
That drastic variation coupled with a 50 percent state and national increase in C-sections over the last decade has inspired a collaboration of virtually every stakeholder in the birthing process: foundations representing patients, doctors, hospitals, insurance companies, state and federal regulators and employers.
Headed by the California Maternal Quality Care Collaborative, their mission is to help hospitals meet the federal Healthy People 2020 C-section target of 23.9 percent for first-time, low-risk deliveries. Currently 60 percent of California hospitals exceed that. One third of all babies in the nation are born through C-section.
The health and financial impacts are huge. Babies born by C-section are more susceptible to infection and respiratory complications and less likely to breastfeed. Women have a higher risk of hemorrhage, transfusions, infections, post-partum depression and they have a 90 percent chance of having another C-section. That increases their risk of experiencing uterine ruptures or hysterectomies, reports the California Health Care Foundation.
C-sections also cost an average of $5,000 more than vaginal deliveries. And related hospital stays and recovery times are double and triple those of vaginal births.
That has caught the interest of large employers. Maternity care is their second largest health care expense, said Brynn Rubinstein, senior manager of the Reform Maternity Care Program at the Pacific Business Group on Health, a consortium of large employers and public agencies, and a partner in the Collaborative.
A toolkit for change
With funding from the California Health Care Foundation, the California Maternal Quality Care Collaborative has released its Toolkit to Support Vaginal Birth and Reduce Primary Cesareans. The group has formed a collaborative of 35 mostly Southern California hospitals which have the highest C-section rates.
The hospitals will work as a whole and in smaller groups led by a mentor physician and nurse to implement measures like encouraging women to labor at home early on. That keeps them active and can help avoid a cascade of unnecessary hospital interventions like early induction of labor.
Hospitals will also focus on educating women about the risks and benefits of all options and moving nurses and doctors from their tendency to treat each delivery as high risk to a more supportive approach helping women with coping techniques for a normal labor and encouraging more use of doulas and midwives.
“It’s easy to rationalize doing a C-section nowadays,” Main said. If a woman is small, labor isn’t progressing well and it looks like she’ll probably have a C-section anyway….. “You can talk yourself into it,” he said.
A critical piece of the new approach is getting doctors to wait.
“Not every woman dilates at one centimeter per hour,” Main said.
“Normal natural labor may take longer that what was previously taught,” said John Wachtel, Chair of the American College of Obstetrics and Gynecology district for California and an executive committee member of the California Maternal Quality Care Collaborative.
Pilot proves improvement possible
Many of the toolkit measures were tested in a 2014 pilot project funded by the Robert Wood Johnson Foundation. The Pacific Business Group on Health used the leverage of its employer members to recruit three southern California hospitals for the pilot. In less than a year all three were able to reduce their C-section rate by an average of 20 percent.
Hoag Memorial Hospital Presbyterian in Newport Beach was one of them. In 2012 Hoag had a 36 percent C-section rate for first-time, low-risk deliveries, said Allyson Brooks, executive medical director of Hoag Women’s Health Institute.
Through its California Maternal Data Center the California Maternal Quality Care Collaborative provided Hoag its C-section rates by doctor compared to other hospitals in the state. Of the 251 California hospitals delivering babies, 170 sign up to get this data.
Hoag released the numbers unblinded. Initially physicians doubted the rates, claiming they couldn’t be true, Brooks said. Some felt it was punitive and shaming. But it spawned results.
“Until recently hospitals and doctors didn’t know what their own rates were,” said Main.
“I think it raises the bar for them and makes them more attentive,” Brooks said. Physicians aren’t so quick to jump to a C-section.
Hoag also moved its labor and delivery nurses, from a central nurses’ station to computers on wheels so they can spend more time supporting patients, keeping them ambulatory and their labor moving and helping to manage their pain, Brooks said.
Educating the public
That kind of support can mean the difference between a vaginal birth and a Cesarean. Vera Fair had her mind set on a C-section. During her first delivery at Hoag the medical team told her her baby was in danger after three hours of pushing and convinced her to have a C-section. So that was her plan for her second delivery.
But her new doctor, Jeffrey Illeck, encouraged her to try a vaginal birth after cesarean or VBAC. Illeck and the nurses gently persisted all the way into labor, explaining the benefits of a faster recovery and more immediate bonding with the baby, Fair said. She finally agreed to at least try to deliver vaginally and with three pushes her daughter was born.
“I can’t believe I wanted a C-section,” she said. When Fair tells people about her VBAC, 90 percent of them don’t even know it’s possible, she said.
“There’s a lot of misconception out there.”
Educating the public will be a big part of the Collaborative’s work. And publishing hospitals’ C-section rates will help women make decisions about where they want to deliver.
There’s no question that C-sections can save lives. But in low-risk deliveries spontaneous labor carries the lowest risk of anyone dying, is the shortest in duration and has the least amount of pain and complications, said David Lagrew, chief integration and accountability officer for MemorialCare Health System in Southern California and an executive committee member of the California Maternal Quality Care Collaborative.
“You don’t want to deprive someone of that.”
Removing financial incentives for C-sections
In the pilot project hospitals were required to negotiate a flat rate with insurers whether the delivery was cesarean or vaginal.
With C-sections costing on average $5,000 more than vaginal births, hospitals in the past would have been crazy to agree to a flat rate, Lagrew said.
But healthcare in general is moving to a system of value-based payment.
“At MemorialCare we’re going to quit getting paid for volume so we need to learn how to do this,” Lagrew said. And it may not mean a huge loss for hospitals. Less surgeries and shorter hospital stays reduce staffing needs and free up beds to serve more people, he said.
Covered California, the state’s health insurance exchange, is also a partner of the Collaborative and in April it released policy stating that all hospitals and physicians contracted with Covered California insurance plans will receive no financial incentives to perform C-sections. And they must meet the 23.9 percent C-section goal by 2019.
The World Health Organization aims even lower with a 10 to 15 percent recommendation. There’s no consensus yet on how low is too low, Wachtel said.
“But we know that 33 percent is too high.”