Science & Sensibility

Whether a woman is having her first baby or has already given birth, whether she is sitting in a prenatal appointment or in the midst of labor, if she is pregnant in the United States, there’s at least a 1 in 3 chance she will find herself hearing some version of the words, “You are going to need a c-section.”

Sometimes those words are spoken and heard with clear knowledge that cesarean is the only reasonable and safe option – a complete placenta previa or severe fetal distress in labor, for instance. But does every woman who hears these words really need a cesarean?  What if it’s a labor that seems to be going nowhere, or a fetal heart rate pattern that is not entirely reassuring, or something in the woman’s medical history that increases her risk slightly?

In these gray area cases, non-medical factors tend to influence decision-making. On the doctor or hospital side, it may be fear of malpractice, financial incentives, protocols, or impatience. On the woman’s side it could be her knowledge and values, her plans for future pregnancies, her own tolerance for risk, and her physical condition and support network that may profoundly affect postoperative recovery.

All “nonmedical factors” are not alike, however. Evidence suggests that factors on the physician and hospital side are exerting a much stronger influence than factors on the woman’s side.

How to correct this imbalance? Enter two new woman-centered tools to assist decision-making around cesareans.  I’m honored to have been involved in the development of both.

Just launched is a new resource from California Watch, a project of the Center for Investigative Journalism.  California Watch conducted an independent review of birth records from California hospitals and showed for the first time that for-profit hospitals have significantly higher c-section rates than not-for-profit hospitals, even when they are serving similar populations. As a companion to a powerful article that explains the findings, California Watch produced a set of “React and Act” tools that are available on their web site, including an open-access database of hospital c-section rates and related outcomes, an expert Q&A (with yours truly as the featured expert), and downloadable primers in English and Spanish for women to print and bring with them to their care provider’s office, childbirth class, or hospital tour.

Also, if you haven’t already heard, Lamaze launched another consumer primer earlier this week.  A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations addresses the most common and pressing questions women face when considering or planning a VBAC and all of the content is derived from the NIH Consensus Conference that was held last spring. It breaks down into understandable language the pros and cons of planned VBAC and planned repeat cesarean, how to make sense of prediction models and candidacy for VBAC, how the risks of VBAC stack up to other obstetric risks, the history of hospital “VBAC bans” and how to challenge them, the critical gaps in the research and how to make choices in spite of them, how to discuss options with a care provider, women’s legal rights and protections, and how to take action to improve VBAC access at the community level. (This resource is web-only for now, but we hope to have printed or print-friendly versions available very soon.)

Please pass these important tools to women and I’d love to hear from readers about how they can be incorporated into childbirth classes.

Amy Romano Uncategorized cesarean, Childbirth Education, practice variation, transparency, VBAC

The Today Show, not known for their excellence in birth journalism, showed a live cesarean on air earlier this week. The birth advocacy community has weighed in on the shoddy reporting and the circumstances of the cesarean, pointing out that the stated indications (“big babies run in the family” and “she was past her due date”) do not in fact justify elective primary cesarean surgery.

When I heard that the cesarean had taken place at Beth Isreal Deaconess Medical Center in Boston, I had an “a-ha” moment: That’s the place where Paul Levy is President and CEO. And he has a blog. And his blog has been a sounding board for ideas about health care reform in general and transparency and practice variation in particular. I decided to leave a comment.

Here’s what I wrote about what I really think about the Red Sox the responsibility of hospital leadership to address problems in maternity care including the excess use of cesarean surgery.

I’m sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.

Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the “normal range” (“25-30%”) reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have “Red Sox Nation plus 1″ but you now also have “NTSV cesarean rate plus one” – the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was “big baby”.)

I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.

(BTW, Paul Batalden’s [whom Levy mentioned in a recent blog post about practice variation] daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)

After another commenter suggested that perhaps the circumstances of the cesarean were a private matter, I had more to say:

I agree that this isn’t an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much “business” the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we’re going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.

Just in the past week, there’s been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California’s maternal mortality rate. Seems like there’s plenty of “blog fodder” other than the Red Sox angle.

Levy’s commitment to openness and transparency is unique in the hospital administration world and I support it wholeheartedly. I have to admit it felt like quite a thrill to leave a cogent comment on a blog of a hospital CEO. Even when I’ve worked for hospitals I never had that kind of access.  Of course listening doesn’t necessarily translate into doing. I hope that Levy recognizes that his hospital could be doing much better in their provision of maternity care to the community, begins documenting quality improvement efforts on his blog, and welcomes the input he receives from those of us who have thought quite a bit about what high-quality, high-value maternity care looks like and how to get there.

*Jill from The Unnecessarean coined this term.

Amy Romano Uncategorized cesarean, hospitals, maternity care systems, media, practice variation, transparency

I’m going to be on Momotics Blog Talk Radio tomorrow evening at 10pm EST discussing the issue of transparency in maternity care with Danielle from Momotics. You can listen here.  For the occasion, I thought I would dig up this fact sheet I wrote for Lamaze a couple of years ago when we first got involved in advocacy on this issue.  I’ve learned a lot since then and have thought for a while that this fact sheet needs to be revised and updated. I’d love thoughts from readers, especially those involved in ongoing efforts to collect and publicize facility data for The Birth Survey. What would you change? What messages need to be more clear? What else do I need to include? Feedback, please!

Why Transparency in Maternity Care Matters: A Fact Sheet for Birth Advocates

What is Transparency?

A pregnant woman asks her care provider, “What is your episiotomy rate?” Her doctor responds, “I only do them when it is necessary.” On her tour of the hospital maternity center, another woman asks about the hospital’s cesarean rate and is told, “We take care of many high risk patients, so you can’t compare our cesarean section rate with the hospital across town.”

What are the consequences when women can’t objectively evaluate the quality of their maternity care options? How do we help women make sense of intervention rates? How can women make fair comparisons?

Transparency means providing health care consumers with the information they need – and the means to interpret it – in order to evaluate the quality of care provided by individual providers and institutions. Transparency is the missing ingredient to truly informed choice.

Are Intervention Rates Important Quality Measures?

A growing body of research shows that among the most important factors influencing a woman’s risk of obstetric interventions, especially cesarean surgery and episiotomy, are where and with whom she gives birth. A recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found cesarean rates for this population ranging from 11% – 30%. Statistical analysis revealed that obstetric practices – not clinical or demographic factors – accounted for over half of the variation across hospitals (1). Two studies conducted in Washington State found that the individual physician was an independent risk factor for cesarean section in both induced and spontaneous labors (2, 3). Several studies have shown that episiotomy is more common in private obstetric practices versus public or university-affiliated practices (4-6). Rates varied from 6% to 60%, but at least one university hospital maintains an episiotomy rate of 1% (7).

Excess use of obstetric interventions, in turn, increases the likelihood that the woman or her baby will be injured, experience complications such as infection, suffer pain, or have negative birth experiences (8). So, in short, a woman who goes to a provider or hospital with a high cesarean section rate is more likely to end up with cesarean surgery – and to suffer its potential consequences. If she goes to a provider with a high episiotomy rate, she is more likely to have an episiotomy – and to suffer its potential consequences. And so on… However, in most states, maternity care providers and facilities are not required by law to publicly report intervention rates or other outcome indicators, nor to help the public interpret data that are available.

Women can not make informed choices about their maternity care if they do not have access to the information that is most likely to influence their outcomes. They can not decrease their exposure to injury from injudicious use of interventions without knowing where and with whom intervention rates are too high. Without transparency, our health care system gives women a false sense of choice.

Can Transparency Improve the Quality of Maternity Care?

Yes! While most of the research on transparency and public reporting relates to other areas of health care, a few studies have looked at maternity care in particular and have found that public reporting of intervention rates and outcomes, whether alone or in combination with other quality improvement programs, translates into better care (9-11). In fact, an experiment conducted in Wisconsin suggests that the quality of obstetric care improves more in response to public reporting than other medical or surgical specialties (9). This may have been because there was more “room for improvement” in maternity care – more hospitals had low scores on obstetric indicators than on cardiac or surgical indicators. In the same study, hospitals included in a public report were more likely than those that were not to undertake quality improvement efforts. These efforts appeared to be effective – maternity units that improved their quality scores were more likely than those that stayed the same or did worse to have begun quality improvement efforts shortly after the public report was released. In other words, public reporting prompted hospitals to work to improve the areas where they scored poorly, and these efforts were effective at improving the quality of care.

Apples and Oranges: How Do We Make Fair Comparisons?

The question of which indicators to measure and how these should be reported complicate efforts to ensure transparency in maternity care. This is particularly problematic when it comes to interpreting cesarean section rates. The overall cesarean section rate (number of cesareans divided by the number of all births) may not be comparable across settings because some hospitals take care of many high risk women while others take care of low-risk women. The rate of cesarean section in high risk women may be higher for good reason. The same is true at the provider level; some providers, including many midwives, specialize in the care of low-risk women while others care for a mixed-risk population or specialize in high risk pregnancies. Similarly, factors such as parity (whether the woman has previously given birth) and age may naturally affect rates of obstetric interventions as well as outcomes.

Healthy People 2010, the federal program that sets goals for various health indicators, measures the cesarean section rate in nulliparous women (those having their first babies), with term (>37 weeks), singleton (one baby), vertex (head down) pregnancies (12). This is abbreviated as the “NTSV cesarean rate” and is used as a proxy for the cesarean section rate in low-risk first time mothers. It has been shown to be highly sensitive to variations in obstetric practices (1), so quality improvement programs should therefore be effective at safely lowering the NTSV cesarean rate. It is also a good measure because, if we can safely prevent the first cesarean, we can prevent repeat cesareans, as well as poor pregnancy outcomes resulting from accumulating many cesarean scars, such as placenta previa, preterm birth, and placenta accreta. As advocates for improvements in maternity care, we should recognize the NTSV cesarean rate as an effective quality indicator, and should educate the public to ask for and know how to interpret NTSV cesarean rates.

However, perfect indicators that can be compared easily across birth settings and providers will not be available in every community. Even when they are, the total rates of cesarean section, episiotomy, and other interventions are important quality measures. In the case of cesarean surgery, many studies have shown that rates can safely be less than 15% in mixed-risk populations, including those where considerable proportions of women have medical problems or are at risk because of poverty, age, or other factors (8, 13, 14). So, while the likelihood of requiring a cesarean will vary with individual circumstances, women with care providers whose rates are 15% or less can trust the their practitioner’s judgment should they recommend a cesarean in their case.

How Can Birth Advocates Promote Transparency?

Ensuring transparency in maternity care will require a major shift from the status quo, with buy-in and participation from hospitals, care providers, insurance companies, government, and consumers. As advocates for mother-friendly maternity care, we can help influence transparency efforts in our communities. In some areas, transparency initiatives are well underway and mother-friendly birth advocates can work to help consumers access and make sense of publicly available information. In communities where there is resistance to transparency, advocates can work to influence legislative efforts, create consumer demand for transparency, or work with the media, hospital administrators, local opinion leaders, or others to promote change. By maintaining a focus on quality improvement and safety rather than penalizing providers or facilities, transparency advocates are likely to gain greater acceptance and involvement from key stakeholders.

References

1. Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51.

2. Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. American Journal of Obstetrics and Gynecology, 191(5), 1511-1515.

3. Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579-85; discussion 1585-7.

4. Goode, K. T., Weiss, P. M., Koller, C., Kimmel, S., & Hess, L. W. (2006). Episiotomy rates in private vs. resident service deliveries: A comparison. The Journal of Reproductive Medicine, 51(3), 190-192.

5. Howden, N. L., Weber, A. M., & Meyn, L. A. (2004). Episiotomy use among residents and faculty compared with private practitioners. Obstetrics and Gynecology, 103(1), 114-118.

6. Robinson, J. N., Norwitz, E. R., Cohen, A. P., & Lieberman, E. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2), 214-218.

7. Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365-372.

8. Goer, H., Leslie, M. S., & Romano, A. (2007). The evidence basis for the 10 steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by the scientific evidence. The Journal of Perinatal Education, 16(1 Suppl), 32-64.

9. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-1160.

10. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). It isn’t just about choice: The potential of a public performance report to affect the public image of hospitals. Medical Care Research and Review, 62(3), 358-371.

11. Wirtschafter, D. D., Danielsen, B. H., Main, E. K., Korst, L. M., Gregory, K. D., Wertz, A., et al. (2006). Promoting antenatal steroid use for fetal maturation: Results from the California perinatal quality care collaborative. The Journal of Pediatrics, 148(5), 606-612.

12. Healthy People 2010. (2000). Objective 16-9. reduce cesarean births among low-risk (full term, singleton, vertex presentation) women. Retrieved 7/16/2007, from http://healthypeople.gov/document/html/objectives/16-09.htm

13. Haire, D. B., & Elsberry, C. C. (1991). Maternity care and outcomes in a high-risk service: The north central Bronx hospital experience. Birth, 18(1), 33-37.

14. Leeman, L., & Leeman, R. (2002). Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. The Journal of Family Practice, 51(2), 129-134.

Amy Romano Uncategorized cesarean, episiotomy, induction, interventions, practice variation, transparency

On September 15 I will give my webinar, Transparency in Maternity Care: Bringing Birth Out of the Dark to Improve Quality. I’ve presented this talk many times before and the feedback is always great. The webinar will give you the evidence to build the case for transparency in maternity care. We will review a body of evidence that shows:

• Intervention rates and outcomes vary widely across providers and facilities
• Most of this variation has to do with factors unrelated to the woman’s health status
• Excess use of interventions leads to excess injury and cost
• Intervention rates can be lowered without compromising safety
• Public awareness of quality indicators results in improved quality
• Mother-friendliness is a measure of quality

Participants will also learn about a grassroots effort to improve transparency in maternity care: The Birth Survey, supported in part by Lamaze International.

Lamaze has approved one contact hour for participants. You can find out more about the webinar and register online.

Amy Romano Lamaze News announcements, interventions, practice variation, safety, transparency

At long last, The Birth Survey has given the public access to consumer ratings of maternity care providers and birth facilities. This is a major step toward increased transparency in maternity care.

I’ve been involved with The Birth Survey for a couple of years and am a vocal proponent of transparency in maternity care. I’ve studied the research on practice variation and concluded that we urgently need to publicize the rates of procedures and outcomes so that women can make informed choices and improve their likelihood of a safe and healthy birth.  The Birth Survey team is on top of this and is working hard to obtain and publicize intervention rates for all birth facilities nationwide.

But what is the evidence that consumer feedback can drive quality improvement? Many analysts have questioned the value of “doctor rating” sites, and some doctors are even vigorously opposing and censoring these sites, a move that is ludicrous and unethical. What makes us think that The Birth Survey will be more effective than some of the consumer rating sites that have apparently failed to drive meaningful change in health care?

First, The Birth Survey is firmly rooted in scientific evidence on what comprises safe and effective maternity care. The questions were formulated from The Mother-Friendly Childbirth Initiative, a model of maternity care that is supported by a large body of medical literature and promotes the rights of childbearing women. Each of Lamaze’s evidence-based Healthy Birth Practices is also represented in the survey questions. Finally, questions about the provider’s interpersonal communication skills were developed and validated by the Agency for Healthcare Research and Quality, the leading federal agency on evidence-based health care.

In addition, women who have given birth may be more motivated to share their experiences than people who have had other types of health care encounters. Many women are eager to share their birth stories, and repositories of birth stories abound on the internet, presumably more so than testimonials about a people’s pneumonia treatments or diabetes management, for example. So we cannot assume that the same limitations of other health care rating sites will apply to women who have given birth.

Finally, women’s satisfaction and the care providers’ interpersonal skills are potent quality indicators in maternity care. Unlike most other health care encounters, women presenting to prenatal appointments or to their birth settings in labor are usually not sick. The “treatment” should therefore be to support and facilitate the normal, healthy processes of labor and birth, and to intervene judiciously with the woman’s fully informed consent only when problems arise. Research on birth physiology strongly suggests that the attitude of the care provider and the qualities of the birth setting can make labor either easier or harder, and can either promote optimal health or trigger complications and overreliance on risky procedures to correct these problems.

As a research enthusiast, I’m very eager to study the effectiveness of The Birth Survey and other transparency initiatives. But whether or not The Birth Survey drives meaningful change in maternity care depends on how many women use it, so spread the word!

Amy Romano Research for Advocacy, Science & Sensibility practice variation, transparency