April 21, 2010
Sidney Wolfe, M.D.
Public Citizen Health Research Group
About New York
Variations in Cesarean Sections, VBACs, and Midwife Availability by County and by Hospital Within Each County
Healthy Outliers: Two New York Hospitals that Have Bucked the Trend
Factors Possibly Associated with Variation in Rates
What is Driving Cesareans in New York?
How a Woman Can Avoid an Unnecessary Cesarean in New York State
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
New York Hospital Birth Statistics by County
What Health Departments and Hospitals Can Do to Reduce Unnecessary Cesareans
While the decision-making of the woman and her practitioner may be key at the individual level, there are system wide interventions that have been found to reduce the prevalence of unnecessary cesarean sections.
1. All hospitals should offer the alternative of licensed-midwife delivery. As discussed in the section on what women can do to avoid unnecessary cesarean sections, this choice for women is currently denied in the 44 hospitals in New York State, including major medical centers in Manhattan, that do not offer midwife delivery. There is no reason why every hospital, located near the offices of midwives, should not offer this cesarean-sparing alternative. Related to this, hospitals should be required to compensate midwives for training residents. This happens informally at some hospitals, and those residents actually get to see some normal labors and births. This practice, including good funding for it, could influence the skill set that obstetricians get in residency.
2. Adopt peer review in all aspects of maternal and fetal care. Physicians should know how they are doing with respect to their colleagues. This includes sharing data on procedures, by type, as well as outcomes. Some hospitals have found that use of comparative outcome data coupled with shared discussion and strong institutional leadership can be an effective tool to curtail practices that are unnecessary as well as costly and potentially harmful. The two elements of this strategy ? information and leadership ? are necessary in order to both identify outliers and hold them accountable for their practice styles. As one researcher has stated, “data, in the absence of recognition, praise, public accord and private admonishments are unlikely to actually change physician behaviors. Many such projects have failed because of lack of committed leadership.”
3. Require all obstetrician-gynecologists to get a second opinion before deciding on a primary cesarean section. Incorporating this measure as a matter of course not only holds physicians responsible to one another, it also creates a culture of mutual accountability within the institution. This also avoids making a decision on other than clinical grounds. Moreover, the second opinion requirement provides pregnant women additional reassurance that the chosen pathway is the medically correct one. Some hospitals have incorporated such a requirement into their written policies. For example, St. Luke’s Roosevelt Hospital Center in New York City states the following in its policy and procedures manual: “Any primary elective C-section requires prior approval by a member of the MFM [Maternal-Fetal Medicine] division” as well as “medical/obstetric justification.” Similar approvals are also required for any elective cesarean performed prior to 39 weeks of gestation.
St. Luke’s also requires a consultation from a member of the Maternal-Fetal Medicine division prior to any induction of labor before 41 weeks of gestation, with a verbal consultation being followed by written documentation in the patient’s chart.  These elective early inductions are one source of subsequent unnecessary cesareans.
4. Use “care bundles” to standardize perinatal care. Care bundles are groups of evidence-based interventions that, adopted together, produce better outcomes than those implemented individually. These have been developed by the Institute for Health Care Improvement and cover different aspects of labor and delivery. A group of 44 hospitals in New York State has been implementing a Perinatal Safety Bundle combining three discrete protocols governing elective induction, labor augmentation, and safety climate. The latter is aimed at avoiding the communication breakdowns associated with 85 percent of all adverse events in obstetrics. The protocols include rapid response drills so that all members of the perinatal team know to react to emergent situations. The hospitals share best practices and clinical information through monthly calls and visits.
5. Eliminate financial incentives for performing cesarean sections. As indicated earlier, physicians are paid more for performing cesarean sections, although these take a much shorter time than a vaginal delivery. This misalignment between compensation and desirable medical practice may act as an incentive for unnecessary cesareans.
Washington State may serve a useful case study of the effect of this approach to reducing the cesarean rate. In 2009, it passed legislation that allows “for the development of patient decision aids to help educate patients, physicians, hospitals, and birth center about the risks and benefits of cesarean delivery.” It also adjusted its fee schedule in line with its objectives. After July 1, 2009, the Washington Medicaid program adjusted its system of DRGs (diagnosis-related groups) to pay for uncomplicated cesarean sections as if they were complicated vaginal deliveries. “The new rules adopted will cut Medicaid reimbursements for uncomplicated C-sections from about $3,600 to around $1,000.” This attempt at reducing the differential in fees is expected to eliminate the potential financial incentive to perform unnecessary procedures. While it is too early to tell if this will achieve the desired end, the experiment bears watching.
Another way to eliminate the financial “reward” that accompanies cesarean section is to pay physicians other than on a fee-for-service basis. Salaried physicians are paid for their time on the job, rather than for the number of procedures performed. And physicians on capitation are paid for the patients under their care, rather than the services rendered. Both modalities avoid the link between procedures and payment.
6. Adopt the practices of the Indian Health Service. Some hospitals within this division of the US Public Health Service takes pride in having lower cesarean rates and higher VBAC rates than those of most states. While some of the outcome indicators may be related to the specific characteristics of the population served, IHS facilities “have labor management practices and policies that favor no use of epidural analgesia and increased use of nurse-midwives and family practice physicians.”
 Main, Elliott K. “Reducing Cesarean Birth Rates with Data-driven Quality Improvement Activities.” Pediatrics 103.374 (1999): 374-83. Web.
 In Latin America, where this policy was tried in a group of 17 hospitals that were matched with a control group of similar hospitals, the former experienced a small but significant reduction in non-emergency c-sections (relative rate reduction, 7 percent). The researchers concluded that a mandatory second opinion policy could prevent 22 intrapartum c-sections for every 1000 deliveries without harmful effects to the baby or the mother. Althabe, Fernando, Jose Belizan, and Jose Villar, et al. “Mandatory Second Opinion to Reduce Rates of Unnecessary Caesarean Sections in Latin American: A Cluster Randomised Controlled Trial.” Lancet 363 (2004): 1934-940. Print.
 St. Luke’s – Roosevelt Hospital Center Department of Obstetrics and Gynecology, Section III.B: Labor and Delivery, Policy III.B.23: Elective C-Sections: 1. 2007. Print.
 St. Luke’s – Roosevelt Hospital Center Department of Obstetrics and Gynecology, Section III.B.: Labor and Delivery, Policy III.B.8.: Oxytocin Administration for Induction or Augmentation of Labor. Policy B.1. 2007. Print.
 Controlling C-Section Growth. Washington State Department of Social & Health Services, 2009. Web. <maa.dshs.wa.org/news/fact/FS009-016ControllingC-sectiongrowth6-15-09.pdf>
 Grady, Denise. “Lessons at Indian Hospital About Births.” New York Times. 6 Mar. 2010. Web. <www.nytimes.com/2010/03/07/health/07birth.html?pagewanted=print>.
 Mahoney, Sheila, and Lorraine H. Malcoe. “Cesarean Delivery in Native American Women: Are Low Rates Explained by Practices Common to the Indian Health Service?” Birth 32.3 (2005): 170-78. Print.