Wednesday, April 27, 2016

Your Hospital Choice Significantly Influences Your Cesarean Risk

Image from Consumer Reports 

Consumer Reports has a new report out for Cesarean Awareness Month, focusing on the variations in cesarean rates at hospitals across the United States. It highlights how different a woman's risk for a cesarean is, depending on which hospital she chooses.

One analysis points out the wide variations in cesarean rates for low-risk mothers in the Consumer Reports investigation. For example, Crouse Hospital in Syracuse, New York had an 11% cesarean rate in low-risk mothers, while Hialeah Hospital in Miami, Florida had a high of 68% for the same group. That kind of massive variation suggests there is more to the cesarean story than simple medical need.

Disclaimer: It's always important to remind people that no one begrudges a cesarean that is truly needed. No one is less of a woman or a mother if she has a cesarean, and it's perfectly okay to be happy with your cesarean. Don't make this about any one person's particular birth story, but rather focus on the big picture.

The big picture here is that over-utilization of cesareans brings significant risks on a public health level. Mothers and babies are being endangered by doing too many cesareans. 

It's time to shine a light on hospitals' cesarean rates so consumers can make fully-educated decisions about where they want to give birth.

Cesarean Rates in Low-Risk Mothers

The Consumer Reports article focuses on the cesarean rate in first-time, low-risk mothers. These rates act as a sort of canary-in-the-coal-mine warning of excessive cesarean rates. Their article explains further (my emphasis):
Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk of needing a cesarean: pregnant women expecting just one child (not twins, triplets, or other multiples) whose babies are delivering at full-term in the proper position, which means coming out head first. 
The target C-section rate for those births, set by the Department of Health and Human Services, is 23.9 percent or less. That’s 10 percent less than the rate for such births in 2007, which the government uses as a baseline from which to improve. 
But many experts say that the ideal C-section rate for those births is even lower. “Getting under 24 percent for low-risk births is something all hospitals should be able to do, but for those deliveries, hospitals should be aiming even lower,” Main says.

Yet nearly six in 10 of the hospitals we looked at had C-section rates above the national target for low-risk births. That means that 40 percent of hospitals already achieved this goal. “This sends a message that almost all hospitals should be able to achieve this rate,” Main says. 
The risk of having a C-section also varied depending on where in the country women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest. 
Three states plus the District of Columbia had C-section rates of 30 percent or higher: Mississippi (31 percent), Kentucky (32 percent), Florida (32 percent), and D.C. (35 percent). 
And four states had rates below 18.5 percent: South Dakota (14 percent), Wyoming (17 percent), New Mexico (18 percent), and North Dakota (18 percent).
It's nonsensical to think that the uteri of women in South Dakota are vastly more efficient than the uteri of women in Mississippi. There is something else influencing cesarean rates here besides true medical need.

The Science and Sensibility analysis points out that hospital culture plays a very strong role in influencing cesarean rates, as demonstrated by wide variations of cesarean rates in hospitals serving the same basic community: 
For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were. 
In southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at nearby Riverside Community Hospital.
According to this analysis, some hospitals have been able to substantially reduce their cesarean rates over time simply by internally publishing the rates for individual providers within the hospital. When care providers saw their rates compared to those of their colleagues, they often changed behaviors that led to a reduction of cesarean rates. 

So why not make the cesarean rates for EVERY hospital in the country publicly available? Perhaps peer pressure can work on a hospital level too.

If hospitals had to acknowledge that other hospitals with similar patient risk levels and demographics could safely have lower cesarean rates than they did, they might put more effort into policies which would help change their own rates.

Transparency in Cesarean Rates

Transparency in healthcare is vitally important. Consumers have the right to know how their local hospitals rate in measures of quality of care, and to make an educated decision on where to take their business as a result.

Many hospitals are already reporting on their infectious morbidity and other measures of quality ─ why shouldn't parents be able to research the cesarean risk at their local hospital? Parents deserve to be able to make an educated choice, yet right now these reports are completely voluntary and many hospitals don't report results at all.

For example, some of the most prominent hospitals in the U.S., like Mount Sinai in New York City or Yale-New Haven in Connecticut, do NOT practice transparency in cesarean rates. The Consumer Reports article notes (my emphasis):
Consumer Reports does not have C-section rates for more than half of the estimated 3,000 U.S. hospitals that deliver babies. That’s because hospitals are not required to publicly report that information, and many choose not to.
This urgently needs to change. Hospitals should be required to have transparency in quality measures such as infectious morbidity and low-risk cesarean rates.

I'd go even further and suggest that the cesarean rates for EVERY PROVIDER be made publicly available. Sure, you can ask your providers their rates, but not every provider tracks this, and some lie about their rates. Providers need to be held accountable for their rates, and we know that publishing rates is effective in reducing non-indicated cesareans.

Most importantly, though, prospective parents deserve to be able to learn about their likelihood of surgery with a particular provider. How can you be an informed partner in your own care when you can't get basic information like about the performance of your hospital and your provider? Consumers have every right to this information. 

Furthermore, transparency can have the added benefit of providing motivation for hospitals and providers to improve their results so consumers are more likely to bring their business. Experience shows that when substandard results are highlighted and a program is developed to address the issues, outcomes can be improved.

Transparency is powerful stuff in healthcare, and it has the potential to motivate major changes.

Kudos to Consumer Reports for shining a major spotlight on this issue. Now it's time for the hospitals who are not being transparent to change their policies and be accountable too. Otherwise, who knows what's really happening in those hospitals? Or how many women are being subjected to the immediate and future risks of major surgery on dubious grounds?

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