On December 18th, 2011, over 50 men and women showed up for a rally for change in front of Mary Birch Hospital for Women. Mary Birch has one of the highest cesarean birth rates for first time mothers in the state of California. That being said, the World Health Organization recommends the cesarean birth rate to be no more than 15%. When it rises above 33%, the maternal death rate rises by 21%. Standing out in front of Mary Birch really became, to me, a responsibility as a birth advocate. Now, I’m not saying that the doctors and nurses don’t have good intentions or that the hospital doesn’t have good intentions to serve women, but the responsibility for lowering this rate has to start somewhere.
Who is truly responsible for the rise of the cesarean birth rate?
The consumers and birth advocates are taking responsibility to rally. Pregnant women, doulas, grandmothers, midwives all stood out in the cold that day to notify the world that change needed to happen. The researchers are taking responsibility, they are showing that the maternal mortality rate is climbing and the neonatal mortality rate has stayed the same since the 1980s. Research is showing that only 30% of obstetrical practice is evidence-based. Some evidence is not being followed. But who is responsible in evidence based implementation? As far as Mary Birch Hospital for Women, It doesn’t matter that Scripps La Jolla has similar statistics. It doesn’t matter that Mary Birch may be a trendsetter or have 6% of high risk patients delivering there. What matters is that as an institution they have power to create change – and they aren’t doing it.
Right now they play the powerless card. Powerless because of many myths regarding the increasing cesarean birth rate…myths that they probably actually believe (see below). I could start by telling them to hire midwives to lower their cesarean birth rates or have an in-house birth center. And what happened to that doula program? That would surely work. But let’s offer some more “obstetrically traditional” ideas to Mary Birch as far as what they can do to lower their rates. I’m interested in assisting them in finding solutions. It’s a human rights issue.
First, educate the mothers during pregnancy as to the risks and realities of induction of labor for both the mother and the baby. This involves breaking down informed consent line by line (initialing bullet points) into parts to show that the family understands the risks of induction or a cesarean for both mom and baby. Document what alternatives were discussed and offered as well.
Second, all inductions should not be “offered” unless “necessary.” Ok, we hit the gray area. I’m not expecting Mary Birch to follow my belief system on induction or what I would say was unnecessary, but the least they could do is follow obstetrical “evidence-based guidelines” as an institution. This means that even some of the “high risk” women that deliver there would not be induced. For a more in depth report check out: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2008.02065.x/full
Third, doctors don’t have any incentive to advocate for a vaginal birth. The hospital and the birth attendants get paid more for a cesarean. However, financial incentives could be given to individual doctors or practices when they lower their cesarean birth rate. Doctors that already have a low rate (below a set amount, let’s say 20%) can be rewarded as well. In hospital privileges of some sort could also be given when a doctor’s rate is lowered.
Fourth, when a doctor’s induction rate consistently correlates with weekends and holidays, the cases need to go to a hospital committee for review. Induction and birth should not be done for convenience factors. There have been health care systems and hospitals that have worked at improving their bottom line and reduced the induction and cesarean birth rate at the same time. Intermountain Health implemented a protocol to avoid unnecessary inductions:
“When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies.”
Fifth, we need to look at such healthcare systems and trials that have proven to lower the cesarean birth rate and maintained quality of care. Mary Birch can learn from those who have already done trials to successfully lower their cesarean birth rates. For instance, Oregon Health and Science University is implementing changes that include encouraging VBACs, giving opportunities for a trial of labor for vaginal birth after 2 cesareans and instituting policies for vaginal breech birth. The head of the Maternal and Fetal Health discusses the robust program for encouraging VBACs: “About three out of four patients are able to have VBACs,” Pereira said. “If you don’t have that policy, then all four of those patients are going to end up with a repeat section.” Also, The White Paper which was produced by the California Maternal Quality Care Collaborative recently released detailed a summary of suggestions of how the cesarean rates could be reduced. Reducing inductions, implementing payment reform so that doctors would be rewarded for quality improvement, encouraging VBACs, and implementing patient education were all suggested.
Wait, didn’t I just write about that?
Myth #1: more women are high risk at their hospital than others (accounts for 6%) Myth #2: There are more cesareans because of fertility drugs and the incidence of twins. Reproductive technologies have improved since the early 2000s and there are less twins being born from women using these technologies. Myth #3: older mothers have driven up the cesarean birth rate. Actually, this may have partly been true, but according Eugene Declerq, the average age of mothers has not increased since 2003 but the cesarean rate has. Myth #4: Babies are bigger. Actually this is false, they have gotten smaller mostly due to induction of labor before babies are able to reach maturity. Myth #5 Mother’s want a cesarean, but after a national poll of mothers, this group of women equalled less than 1%. Myth #6: Induction doesn’t increase the cesarean birth rate. A first time mom being induced has a 50% more chance of having a cesarean if she is induced as opposed to not being induced. Myth #7: Vaginal breech birth isn’t as safe as a cesarean. Guess again, the original Hannnah study has been refuted. Please suggest more myths, I know there are more out there…