Photo by Christian Bowen | Unsplash
In 2005, the staff at Beth Israel Deaconess Medical Center (BIDMC) in Boston noted the rise in the cesarean rate in the United States with deep concern. From 1996 to 2012, the rate increased from 20.7 percent to 32.8 percent. Research indicated this increase was greater than in most other developed countries, signifying that it was not just a result of access to technology. Also, the wide variation among regions and facilities couldn’t be explained based on maternal or fetal factors.
While cesareans are an important obstetric intervention, they should only be used when indicated. Like any major surgery, cesareans present both short- and long-term risks. The short-term risks of cesareans include greater blood loss, increased risk of infection, and blood clots. Long-term risks for the patient include abnormal placentation (which can be life-threatening) and abdominal adhesions that can cause additional complications.
Cesareans can also potentially harm both the patient and the baby. The procedure can interfere with breastfeeding and babies born by cesarean can have more difficulty breathing. Research indicates that a woman whose first birth is by cesarean is likely to have repeated cesareans, and the risk of complications increases with each additional cesarean birth.
For all these reasons, the team at BIDMC decided to act. Their Nulliparous, Term, Singleton, Vertex (NTSV) cesarean birth rate — which identifies the proportion of live babies born at or beyond 37 weeks to women in their first pregnancy, that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions), via cesarean birth — was about 35 percent. BIDMC resolved to do what they could to bring down this rate.
Led by Toni Golen, MD, BIDMC’s Acting Chief, Department of Obstetrics/Gynecology and others, the team selected the following five interventions, which they implemented serially over time:
- Use objective communication about fetal heart rate tracings — Leaders recognized that staff were often using subjective impressions to determine whether a cesarean was needed. They sought to eliminate subjective terminology from descriptions of fetal heart rate tracings, like “dicey” or “dippy,” that had no scientific or physiological basis. Instead, they standardized verbal and written communication regarding fetal heart rate tracings based on terminology and definitions defined by the NICHD.
- Encourage vaginal birth after cesarean (VBAC) — The team established a support system for their physicians to encourage attempting VBAC. A culture in which VBAC is supported is also an environment that places high value on vaginal birth overall.
- Respect each person’s labor — Another culture change they introduced was an attitude of physiologic humility. This meant respecting the course of each person’s individual labor. “From an evolutionary standpoint, labor ought to work,” said Golen. “Otherwise we wouldn’t all be here.” For example, they knew that patients with continuous labor support (e.g., from friends and family or a trained birth attendant) are more likely to have a vaginal delivery. But the hospital had a restrictive policy that allowed only two support people to be in the room throughout the entire labor, and those two people couldn’t alternate with others. As part of this intervention, the hospital liberalized that policy, allowing more people to be in the room to provide labor support.
- Reducing pressure on the Labor & Delivery (L&D) Department — L&D experienced pressure, whether subtle or overt, to “get stuff done.” Leaders had a theory that staff were (perhaps subconsciously) responding to this by inclining toward cesareans, which result in quicker resolutions of labor. “Our hypothesis was that physicians were feeling production pressure, at least in part, because of the unpredictability of clinical activity on L&D. Some of that clinical activity was in fact possible to organize, standardize and execute in a timely way. By creating an on-time scheduled cesarean system, physicians could plan out their day better, and were less inclined to expedite a delivery with a cesarean,” said Golen.
- Use data for improvement — As they introduced the interventions, the team continually measured their effects on cesarean rates and reported back to physicians and other staff. They also used balancing measures to watch for unintended harmful consequences, including avoiding cesareans that were indicated. The neonatal balancing measures were gestational age, birth weight, Apgar scores, NICU admissions, meconium aspiration, and shoulder dystocia. The maternal balancing measures were episiotomy, third-degree and fourth-degree laceration, and blood transfusion.
According to Chloe Zera, MD, MPH, Director of Obstetric Population Health at BIDMC, the team also asked, “Are we achieving improvements across all different populations? There’s no quality without equity.” They emphasize the importance of collecting data across different populations of patients. They did so retrospectively, but they now say they would have looked at this data in real time.
As a result of their interventions, the cesarean rate at BIDMC did decrease. For each year and each intervention, they saw a steady decline. Their NTSV cesarean rate ultimately declined to about 23 percent, although it has plateaued and hovered there since 2015. But that rate may be satisfactory; in fact, the goal of Healthy People 2020 (an initiative of the US Office of Disease Prevention and Health Promotion) is an NTSV cesarean rate of 23.9 percent.
The most challenging part of this project involved the behavioral and cultural changes. For example, when they liberalized the policy to allow more labor support, staff initially found it challenging. As Golen recalled, staff had “fears associated with greater crowds, greater confusion, lack of sense of control.” However, they grew accustomed to it, and it “turned out to be a happy story in the end.”
As Zera said, “Culture change has been accomplished very effectively and it’s cool to be a part of it.”
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