One hospital’s evidence-based approach to reducing C-section rates
In the U.S., Caesarean deliveries are twice as common as they should be. So health care facilities are creating policies designed to drive the numbers down.
By WP BrandStudio
The most common major surgery in America for women isn’t knee or hip replacement surgery—it’s a Caesarean section.
One in every three births in the U.S. happens via C-section, a rate that has increased by more than 500 percent since the 1970s. This rise is due to a constellation of factors, including increased maternal age, inconsistent protocols and misconceptions about the risks and benefits of getting a C-section.
And while some of these surgeries are medically necessary, about half of them aren’t. The World Health Organization (WHO) recommends that no more than 15 percent of childbirths be performed via C-Section, since any number higher than that isn’t proven to reduce maternal mortality or mitigate the risks of childbirth. Knowing this, hospitals are doubling down on efforts to reduce the amount of C-sections that are performed nationwide.
Virginia Hospital Center (VHC), a healthcare facility in Arlington, Va., is one such hospital. In 2014, VHC discovered that their C-section rate was 33 percent—much higher than the limit recommended by the WHO and the American College of Obstetrics and Gynecology (ACOG).
So they pulled together their leadership, medical and registered nurse teams and designed an evidence-based approach that analyzes every single C-section performed in the hospital. If C-sections are found to be higher than the recommended standard, they work with obstetricians to ensure that those rates go down—and that they’re always treating patients in the best way possible.
The health risks of a high C-section rate
When performed unnecessarily, C-sections pose a significant risk to patients, said Dr. Miguel A. Fernandez, chief of the OB/GYN department at VHC; they can put women in danger of experiencing more blood loss during childbirth, as well as scarring, anemia, extended pain, increased postpartum complications and even a higher likelihood of death.
Dr. Jeff DiLisi, VHC’s senior vice president and chief medical officer, also reminds people that “a C-section is an abdominal surgery,” and a major one. Unlike many other surgeries, which can be scaled back to be minimally invasive, a C-section always involves substantial tissue disruption. And it comes with the same risks as any major surgery, including infection and adverse reactions to anesthesia.
To reduce the amount of procedures that were putting patients at undue risk, VHC looked to tackle the high rate of C-sections at the hospital. First, they adopted the new recommendations for labor management recommended by the ACOG and the National Institute of Child Health and Human Development, which offered updated information about fetal monitoring and the use of pain medicine. Additionally, they encouraged more vaginal births after Caesarean, or VBACs. There is a persistent misconception, said Fernandez, that once a woman has had a C-section, she will never again be able to give birth vaginally. But about 75 percent of women treated at VHC who have had a C-section are candidates for VBACs in future births—and if all 75 percent of those women choose vaginal birth, the rate of C-sections could go down.
To further deter mothers from opting into C-sections, physicians at VHC regularly inform their patients about the value and safety that vaginal deliveries can bring. Babies born vaginally often have fewer breathing issues than those delivered via C-section, for instance, and they’re exposed to immune-boosting bacteria when they pass through the vaginal canal.
The squeezing that happens during vaginal childbirth “also helps the mother’s uterus contract back to normal size once the baby is delivered,” said Dena Carey, a registered nurse and the associate vice president of women and infant health at VHC. During a C-section, “you don’t have that and the mom’s body has to adapt to that new method of delivery.”
Improving outcomes
Since discovering that their C-section rate was higher than it needed to be, VHC has implemented a policy of radical transparency that reviews every Caesarean delivery that happens each month. The specifics of the procedures are reviewed by Dr. Fernandez and three other OBGYN department leaders at VHC, who pore over the details and decide whether or not the C-section was medically necessary.
If they find that any doctors have performed C-sections that could have been avoided, they collect three to six months’ worth of data about that doctor’s practice and report back to them about all of the instances where they could have done things differently. Already, they’ve seen this tactic drive down their C-section rates.
At other hospitals, Fernandez said, such a policy could create friction—doctors who receive that information might not immediately accept it and could be reluctant to change. But many of the physicians at VHC’s obstetrics department have worked together for decades, some of them having known each other since their residencies; these long-standing relationships make it easier for the team to have honest, clear communication.
VHC also has protocols to ensure that patients don’t request C-sections in unnecessary situations. If women planning on a vaginal delivery become concerned about the amount of time labor is taking, or if they are fearful about the pain of childbirth, doctors and nurses support them through the process and do their best to encourage them to stick to their plans.
VHC treatment teams also have tools on hand to make childbirth more manageable for mothers; in addition to epidurals, they offer natural solutions to the pain and emotional difficulties that come along with labor.
“We use birthing balls to help [women] manage contractions,” said Carey. She noted that the hospital also uses breathing techniques, meditation, massage and music therapy to help soothe mothers during labor.
The on-call team will do whatever it takes to support women, keep them informed and comfortable throughout the birth process and make sure that they do not have surgery unless it’s absolutely needed. That’s a huge plus for many expecting moms; a study in the journal Birth found that more than 40 percent of women would travel 20 miles to go to a hospital that has a reduced rate of C-sections.
Preparing for long-term success
When Virginia Hospital Center first set out to improve their C-section rates, they aimed to get the rate down to 24 percent, a number they believed was realistic and attainable based on where they began. Today, they’ve surpassed that goal.
“In the last couple of years, we’ve been at 21 to 22 percent,” said Fernandez.
Already, the hospital is seeing the benefits of that borne out. “In-hospital complications have decreased because we’ve decreased the Cesarean section rate,” said Fernandez.
That ripple effect is happening in other hospitals, too, Fernandez continued; one hospital in California reduced their C-section rates and immediately saw improvements in maternal health and safety. Given the fact that the United States has the highest maternal mortality rate in the developed world, this kind of widespread change could have a significant impact on how safe it is to have a child in the U.S.—and make a difference in public health.
And, for the staff at VHC, that’s been the point all along. “We’re constantly focused on what’s in the best interest of our patients,” said DiLisi. “That is what sets VHC apart from other hospitals.”
Learn more about the OBGYN services at Virginia Hospital Center.