Patience, labor and best practices

For the past 40 years, the U.S. Surgeon General has set forth a framework for tracking and reporting on the nation’s health goals and objectives. We are two and a half short years from the year 2020 -- the target set for U.S. healthcare improvements delineated in Healthy People 2020.

One of those goals for Maternal and Fetal Health is lowering the U.S. Cesarean section rate for women without prior Cesarean births from 26.5 percent to 23.9 percent, and for women with a prior Cesarean from 90.8 percent to 81.7 percent -- a ten percent reduction in each population.

Collectively -- and alarmingly -- we are not close to reaching that key benchmark goal.

This initiative is critically important in maternal/fetal health. A surgical birth can add risk to a mother and her child. Women who undergo the procedure may experience hemorrhage, infection, longer recovery, and the possibility for a life-threatening condition (placenta accreta) in subsequent pregnancies. Additionally, it’s 90 percent more likely that a woman who has her first baby by Cesarean will deliver by Cesarean for subsequent births, each with a higher risk of significant complications.

A recent Consumer Reports investigation found that six in 10 hospitals studied had Cesarean rates above the national target rate for low-risk births, and that the average Cesarean rate for first-time mothers who are considered “low risk” (singleton pregnancy, full-term and positioned head down) was 25.8 percent. Research has shown that where a woman chooses to deliver her baby has a profound impact on her likelihood for a Cesarean outcome. Hospitals in the same region of the country show variation, sometimes even 15-fold, ranging from 2.4 percent to 36.5 percent for low-risk women and 10-fold, from 7.1 percent to 69.9 percent for all women.

Why are these rates so high? And why is there such discrepancy between hospitals? Some healthcare observers attribute it to greater reliance on the sensitive monitoring technologies that clinicians rely on to determine fetal distress, while others cite evolving maternal factors such as advanced maternal age, medical co-morbidities and overall health status. But in general, across hospitals and even within individual facilities, I believe there is simply great variation regarding clinical indications for “necessity” as well as the amount of time that OB/GYNs consider an acceptable window for a vaginal birth, otherwise known as patience.

Many Cesareans are, of course, medically indicated. But many are not. At Bakersfield Memorial Hospital in California, where I work as an OB hospitalist, our administrators made decreasing the Cesarean rate and increasing patient safety and use of protocols an executive and departmental priority in 2011. Since that time we completed a top-down review and identified multiple quality improvement and patient care opportunities. As a result, our Cesarean rate for first-time mothers/low-risk deliveries is about 13 percent – roughly half the national target goal rate.

So why aren’t more hospitals able to cut their Cesarean rates?

C-suite executives, from large health systems to small community providers, may believe they are already doing all they can. Based on our experience at Bakersfield Memorial, here are three additional initiatives hospital executives can consider to support women in labor, reduce Cesarean rates, and limit their organization’s risk:

Make an institution-wide commitment to physician education and standardization of clinical indications for vaginal birth versus Cesarean. When goals are clearly articulated – “we will reach or surpass the Health People 2020 goal by 2019” – and supporting strategies are collaboratively determined, there is a far greater chance of reaching the goal. This requires a three step process: adoption, education and integration.

Existing resources, such as the clinical toolkit from the California Maternal Quality Care Collaborative (CMQCC) in conjunction with California Health Care Foundation, offer clinical guidance on early labor policies. Once goals are established and agreed upon by physician and nursing staff, a plan for mandatory clinician education ensures that all stakeholders are aligned and speaking the same language. Next, protocols are written and enacted that support patience and vigilance when indications for Cesarean are not present. Lastly, robust departmental oversight ensures that standardization across provider, patient mix, time of day, and other factors is followed.

Implement an OB hospitalist program. Two of the most obvious benefits of an OB hospitalist program are the care of laboring patients and of obstetric emergencies. Having a physician present at all times, 24/7, limits risk to nursing and physician staff and the hospital. In addition to providing consistent oversight from clinicians experienced in assessing and treating patients with complex medical presentations, an OB hospitalist can help minimize the pressure on community physicians to balance practice in the office/operating room, with the rigors of labor management. Whether in surgery, or in the office seeing patients, an OB hospitalist can offer assistance and expertise to the community providers with induction, fetal heart rate interpretation, rupture of membranes, IUPC/FSE placement, being the provider of record in-house should a patient wish to attempt VBAC, and many other procedures.

The best of OB hospitalist programs also guide care and quality improvements, contributing to elevated skills of every member of the care team. As Ob Hospitalists with Ob Hospital Group (OBHG), we proactively manage risk and identify opportunities to deploy best practices and protocols, based on national evidence-based dataset from programs across the country. While some organizations also collect and disseminate this data, such as the California Maternal Data Center (MDC), hospitals with OBHG programs can track progress in real time and institute quality improvement initiatives at the clinician-level based on real-time metrics.

For example, at Bakersfield Memorial we determined that elective inductions of labor before the 39th week should be eliminated, and we required evidence-based documentation of gestational age based on ACOG standards. We offer multiple methods for labor induction, mechanical and pharmacological. We required coursework and testing on electronic fetal monitoring by our nurses and physicians. When nurses and physicians speak the same language, better care results. Lastly, we implemented “6 is the new 4,” so that women admitted for labor were truly in labor, and we allowed for greater time in labor, thus decreasing the number of labor arrest diagnoses.

Shake up the status quo at the clinician, and even patient, level. Some hospitals with the lowest Cesarean rates have pursued out-of-the-box initiatives and shared decision-making -- some of which may have been unimaginable just a decade ago.

For example, some hospitals engage in peer-to-peer transparency initiatives, in which individual doctors’ Cesarean rates are circulated internally. This method of culture change typically meets initial resistance, however, when pursued in a collaborative and non-punitive fashion, can lead to constructive dialogue and best practice-sharing among OB hospitalists and community providers.

We also work collaboratively to better understand what we can improve upon, and involve every member of the care team. Working as a team with shared goals helps to bring about better outcomes; clinical standardization also results in decreased liability claims. The national frequency of OB claims is about 10 percent; the rate at OBHG-contracting hospitals is about 4 percent; similarly, the number of births resulting in indemnity claims is 1 in 3,711 births at hospitals nationally; OBHG’s claim rate is 1 in 20,000.

A key part of our shared decision-making effort is encouraging patients to collaborate and weigh in on their preferences. Traditionally, patients have not been part of the dialogue on Cesarean versus vaginal birth, but a 2013 study in the National Bureau of Economic Research found when patients are themselves doctors, and presumably better-informed, Cesareans are less common. That should always be the case. Patients should share their goals with their care team, and be reassured that they will not feel pressured for a Cesarean unless it is medically indicated. Empowered patients are the centerpiece of the Joint Commission’s SpeakUp™ campaign, including the “ABC of Cesareans” effort.

There is much to celebrate in maternal/fetal health. According to the most recent Healthy People 2020 update, the infant mortality rate has decreased about 9 percent, from 6.7 deaths under one year per 1,000 live births to 6.1, approaching the Healthy People 2020 target of 6.0 deaths per 1,000 live births. With a concerted effort, hospitals can help to achieve the same success with Cesarean rates, ensuring optimally safe and healthy experiences for mothers and babies.

Dr. Jane van Dis, MD, FACOG, is a Board Certified OB/GYN and Medical Director for Business Development for Ob Hospitalist Group. Dr. van Dis serves as an Ob Hospitalist and as Chair of the Department of Obstetrics & Gynecology at Bakersfield Memorial Hospital in Bakersfield, CA. Prior to joining OBHG, she served six years in private practice.

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