I recently heard Neel Shah, M.D., an obstetrician at Beth Israel Deaconess Medical Center, the founder of Costs of Care, and associate faculty at Ariadne Labs (more about all of that here) speak about health care quality and delivering babies.
We’ve all heard about unnecessary cesarean sections (and elective induced early births, although that’s a related but not identical set of challenges). Many of us tend to think of it as a doctor-centered issue. Some doctors perform more C-sections than others and there are a host of reasons, ranging from how and where they were trained to how they assess and tolerate maternal risk to time management and financial considerations.
But Shah challenged me to think of unnecessary C-sections as a hospital management or system engineering problem – not just a problem created by individual doctors.
The way that labor and delivery systems are organized – the physical set up, the workforce, the use of resources – influences how decisions are made about C-sections. And there’s a huge amount of variation, from hospital to hospital, a 10-fold variation. Nationally the rate varies from 7 percent to 70 percent of births. There’s variation even in hospitals that are close geographically – and Neel points out much of the variation appears to be independent from women’s true risks and preferences.
Here’s a summary of his message – and below you’ll find some resources that may help you write about this topic in hospitals in your state or community.
Envision a busy hospital labor and delivery room department: In 21st century America, it’s comparable to an ICU, with a huge amount of monitoring, a relatively high nurse-patient ratio, and its own operating room(s).
The charge nurse is watching two big LCD monitors, covering the 28 nurses she’s supervising (and yes, the nurse is probably a she.)
There are four more huge screens with information about the 22 labor and delivery rooms and the five ORs. She’s also watching eight smaller screens feeding data from 20 fetal heart monitors.
And there’s an old-fashioned whiteboard-style dashboard about the rest of the floor – who, what, and where, including the physicians.
She has to manage it all, a conveyer belt of birth. Shah calls it the “Pressure Tank.”
How many beds are being used? How long has the woman been in labor – and how much more time is likely? How many nurses are on duty? How long are their shifts? It’s a sauce of workload, availability of resources and accountability. A cesarean takes the equivalent of two hours of “clinical attention.” A regular delivery takes 20 hours of “clinical attention.”
A C-section is just easier for the hospital – and it brings in more money.
“Pressure,” Shah said, ”builds for the two-hour solution.”
But we’re in a new era of accountability – patients, not just policymakers, are demanding accountability for use of resources.
And there’s a growing recognition that unnecessary care can cause harm – including harm to a woman undergoing a C-section. Harm can occur at the time (blood clot, hospital-acquired infection, etc.),or in subsequent pregnancies (scarring that increases risk of a condition like placenta previa.)
Shah was trained to think like a doctor – but now he’s also trying to think like an engineer. And he’s far more aware of his environment.
“When I’m on the labor floor now, I know how many nurses there are, how many rooms are occupied. I think about management.”
But that’s him. It’s not how most doctors think. And that’s probably going to have to change.
And hospitals have to think about it too. Some are working with Ariadne Labs to study how to re-engineer Labor and Delivery to bring down the C-section rate. Others are figuring it out on their own.
What’s going on in your community?
- Here’s a link to a webinar Shah did with Atul Gawande on the “Pressure Tank” last year – including some pretty frightening charts about the rising C-section rate, the cost, the risk (and how factors like the widespread introduction of fetal monitors played out).
- Here’s a recent Perspective essay Shah wrote about hospital vs. home and birthing center births in the U.K. and the U.S. in the New England Journal of Medicine, and related essay for The Conversation, which includes some details about C-section rates and risks.
- Here’s a piece Anna Gorman wrote about how one California hospital brought down its rates under pressure from an insurer that was threatening to cut the hospital from its network.
- Here’s a WBUR report on the variation in C-section rates at Boston hospitals.
- Here’s some Consumers Reports information on unnecessary C-sections and hospital ratings and here’s Leapfrog’s input.
- Here’s a New York Times “Fixes” essay on how San Francisco General uses evidence-based medicine to keep its rates low.
- The World Health Organization published a report in 2010, “The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage.”
You get the idea – send us stories you write on this, and we’ll follow up.