In Brazil, C-section deliveries are the norm, rather than the exception — more than 80 percent of deliveries in private hospitals are C-sections and nearly 50 percent in public hospitals. We asked Paulo Borem, MD, about his project to improve the rates in the IHI Improvement Advisor Program.
IHI: Why are C-section rates so high in Brazil?
Paulo Borem: The main factor is the way we organize care delivery. In the private sector, obstetricians exclusively attend their own patients for prenatal care and delivery. To be able to provide this individualized service, most doctors perform elective C-sections so they can accommodate patients within their “office hours” scheduling needs. Therefore, care is planned according to the obstetrician’s needs.
For the last 20 years, C-section-based care has been the accepted — and expected — care practice, thus convincing pregnant women that delivering by scheduled C-section is more convenient and free of risks.
The type of vaginal delivery historically offered in Brazil is another factor to consider. Obstetricians usually assist births in a surgical environment, with the practice of many interventions such as episiotomy, augmentation of labor, fasting, enemas and shaving, not following the recommendations of the best practices or the evolution of these concepts over the past decades. In the minds of Brazilian pregnant women, the uncertainties and potential trauma of labor and delivery conveys a fearful scenario compared to the predictable and controlled procedure of a scheduled C-section. In the Brazilians’ collective memory, vaginal birth is equated with pain and suffering. Many obstetricians also are out of practice in assisting a vaginal delivery and medical schools only teach future obstetricians how to perform C-sections. Outdated obstetrical practices are the norm in these institutions.
The current payment model based on fee-for-service plays just a moderate role in the high percentage of C-section deliveries in Brazil.
IHI: Given the cultural challenges to change existing practice, why did Unimed Jaboticabal decide to begin work to reduce C-section deliveries?
PB: The director of the hospital and the director of the health insurance plan were very disturbed by high neonatal intensive care unit (NICU) admission rates associated with C-section births. They wanted to do something about it but didn’t know how. They had the will, not the how. Therefore, when I started my Improvement Advisor program at IHI, I introduced the team to the science of improvement. It was a match made in heaven.
Applying the IHI improvement methodology brought confidence to the team and helped us organize the work and clearly track the results. Before the improvement project, the natural (vaginal delivery) birth rate was around 3 percent. Once we began making improvement, after three months the vaginal delivery rate increased to 20 percent. We were surprised and very excited. After nine months, the rate reached 40 percent.
The hospital leadership’s strong will for making change was key for us to keep moving forward.
IHI: What changes did you introduce or test in Unimed facilities to reduce C-section rates?
PB: We’ve been working on three primary drivers.
Buy-in from patients, health professionals, and the community
The Unimed teams redesigned the education course for pregnant women and families, emphasizing the importance of natural birth and introducing new practices such as no fasting during labor, no need for episiotomy in any vaginal birth, the right to have a companion present during birth, among other topics. The leadership and the project team had meetings with all stakeholders to explain the new care model, including the Consumer’s Defense Organization, the local medical association, physicians, hospital employees, and the justice court.
Redesigning the care model
The key changes Unimed implemented included adoption of a shift system for obstetricians; the inclusion of an obstetrics nurse in the care team; and active participation by obstetricians and nurses in prenatal care after 34 weeks, giving pregnant women the opportunity to get to know all members of the team responsible for assisting in the delivery. Obstetricians also agreed on a set of protocols and practice was standardized for prenatal care through to post-delivery care.
Provider reimbursement models
In the new model, obstetricians are reimbursed for the shift rather than on a fee-for-service basis, and the amount paid refers to the percentage of natural birth deliveries.
In many cases, remodeling the physical space for maternity wards within hospitals (to provide a more comfortable delivery experience based on best practices) came later in the process to avoid hospitals using the budget as an excuse for not reviewing the care model.
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IHI: What were the care providers’ (doctors, nurses) first reactions to these changes?
PB: The obstetricians were very resistant. Apparently, for them, everything was fine — no pregnant women had died, they were not aware of complications, and the families and pregnant women were not complaining. They had organized their lives around the elective C-sections. So, why change?
Some obstetricians quit the project; they never believed in it. Others, we had to fire because of misbehavior and for not following the new standards. It was painful. We had to have very strong leadership. The nurses, on the contrary, were early adopters. They embraced the changes and supported the project team and the leadership. They were essential for the change.
IHI: Was there an effort to engage mothers in this initiative? How was the effort perceived by women and their families, and did that perception change over time?
PB: Another important driver for the changes we implemented was family engagement. We redesigned the educational course to prepare the mother and family for a natural birth. We explained that the new care model focuses on safety and quality. However, we made a point to highlight that the obstetrician providing prenatal care would not necessarily be the one assisting in the birth.
Pregnant women and their families did not buy into the idea right away. It was difficult for them to understand this new rule. At first, they did not accept it, especially those mothers who were close to their due date. It took nine months for us to notice a major cultural change. Women who became pregnant after the transition to the new care model were more willing to accept the changes.
When we reached 71 percent of women delivering by natural birth in Jaboticabal, São Paulo, the whole city was talking about it. There was still a lot of misunderstanding about our intentions. People started posting on social media, accusing us of not performing C-sections at all and forcing pregnant women to have a vaginal delivery. It sounds crazy that people would ask for a C-section even when it was not for a medical reason. This distortion was the result of a 20-year-old C-section culture, strongly reinforced by the health care system.
Unfortunately, as a result of this negative reaction on social media and in the press, the vaginal delivery rate went back down to 20 percent. The solution was to join with others to support the changes and to raise both public and professional awareness about why we were implementing the new care model. We held a public meeting in conjunction with the Municipal Secretary of Health, the regulatory agency, non-governmental organizations that support natural birth in Brazil, the Ministry of Health, and the Brazilian Society of Obstetricians and Gynecologists. The public meeting had large participation from the whole community and was a big hit. After this event, the community was more informed and started to support the initiative. The natural birth delivery rate went back up to around 50 percent.
IHI: What surprised you?
PB: I was surprised about how misinformed the families, pregnant women, and the community are about birth. Some obstetricians’ behavior also shocked us. There is no evidence for elective C-sections, but they still resisted. In addition, what is worse, they were professedly against the changes, instigating the families and pregnant women to fight back and restore the old model of care based on C-section deliveries. The strongly held belief in Brazilian culture of a C-section delivery being a pregnant woman’s right was quite surprising.
IHI: How long did it take before you felt the big shift happening?
PB: Just by the end of the first year of the project. At that point, we felt that there was no way back.
IHI: If you had to do it over again, what would you do differently?
PB: I would introduce the changes slowly. I would also integrate the family and the community more deeply from the beginning. Introducing pay for performance for the obstetricians caused more friction than benefit. I don’t recommend incorporating this element in the equation. Much more training on how to assist natural birth should be offered to frontline care providers. The few complications teams encountered were due to analgesia and the lack of knowledge about the best practices available.
IHI: What is the next step? Is there a continued effort to reduce C-section rates, or maybe to spread the changes to other private or public hospitals?
PB: The results of this pilot in the city of Jaboticabal, located in the countryside of the state of São Paulo, were so impressive that three more sites adopted the same package of changes with similar results. These results called the attention of the Brazilian Health Regulatory Agency — ANS. They asked for IHI’s help to implement these changes on a larger scale. After many months of discussion, an agreement was signed between ANS, IHI, and Hospital Israelita Albert Einstein, considered one of the best hospitals in Latin America, to implement the changes in 28 hospitals — 23 hospitals from the private sector and 5 from the public sector. The aim of this larger effort, which began in May 2015, is to increase the rate of vaginal births, improve the quality of care, and reduce the per capita cost in these 28 hospitals.
IHI: Do you anticipate challenges in sustaining these improvements over the long term?
PB: The biggest challenge is to keep the team focused on the pregnant women and the babies’ needs. For many years, the maternal care system was organized around the physician’s needs. The subject most discussed was the obstetricians’ remuneration. It is not easy for the improvement team to move the agenda toward safety and quality of care. It is a constant effort to remind obstetricians that we are here for the pregnant women, their families, and the babies.
IHI: Are there lessons from this work that you would apply to your next quality improvement initiative?
PB: Absolutely. The need for early and profound engagement of the community is key. Pay for performance schemes should be avoided. They are toxic to the system and divert attention away from the quality and safety components of care.
Big efforts should be made to emphasize that the needs of pregnant women, their babies, and their families are at the center of the health system, not the doctors. To engage doctors in this work, we need to offer better alternatives to organize their work around the needs of the pregnant women, babies, and families.
Fewer interventions generally yield better results. This was a painful lesson since the few adverse events we had were related to analgesia. Only very well-trained anesthesiologists should perform analgesia. This has already been said, but it cannot be stressed enough: Teams need constant training to provide the best care based on quality and safety.
Overall, this work has been an incredible experience. We are changing a system that has been this way in Brazil for the last 20 years. The pregnant women and their families did not ask for this change, which makes it even more challenging. We knew it was the right thing to do. Too many babies were being admitted to the NICU as a result of elective C-section delivery.
Someone had to stand up and do something to protect our babies; they cannot speak for themselves. We speak up for them and, more importantly, act for them, supported by the right methodology and motivated by what is most important for the pregnant women, their babies, and their families.
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