People who love numbers talk about how data can tell powerful stories. What's equally exciting is how data can help spur collective action. I experienced this firsthand when I moderated a discussion in Sacramento last week on maternity care in California. (See the video of the briefing.)
In the last 15 years, California has seen worrisome increases in death rates for mothers in childbirth and of babies delivered by cesarean section. C-section deliveries have jumped 50% over the last decade, despite a lack of evidence that they are a better form of delivery than natural childbirth for most mothers and babies. In fact, there's evidence they're worse, especially when related to early elective inductions.
Poor maternity care can cause extended (and sometimes lifelong) repercussions for mothers and babies, including subsequent c-sections for the mother and developmental problems for the child. And at a time when greater medical knowledge is enabling so many Americans to live longer, healthier lives, others face serious preventable problems right out of the gate.
This is why data presented by Dr. Elliott Main, an obstetrician who specializes in high-risk deliveries and directs the California Maternal Quality Care Collaborative, are proving so hopeful. The collaborative works with hospitals, providers, health plans, state agencies, and others to improve maternity care. It also operates the California Maternal Data Center (CMDC), which is currently funded by CHCF and the US Centers for Disease Control and Prevention. (See a video on the CMDC.)
Improving C-Section Rates
According to Dr. Main, of the approximately 475,000 births in California every year, one in three is by c-section. A c-section is major surgery; it comes with increased risk of infections and complications and drives medical costs higher.
Of course, there are high-risk pregnancies where a c-section makes sense to ensure the safety of mom and baby. But, as is the case with so much of the unwarranted variation in medicine, the c-section rate today is driven by the medical practice culture. This includes malpractice concerns and the more predictable timing of a c-section delivery compared to a vaginal delivery.
As Dr. Main pointed out, c-sections have a ripple effect: A woman who delivers her first child by c-section has a 90% likelihood that subsequent births will be by c-section too. If we can lower the c-section rate among low-risk, first-birth moms, it can go a long way to lowering the overall, ongoing c-section rate.
Last year, armed with data compiled by CMDC, Dr. Main's group began a pilot project with a Southern California hospital to lower its c-section rate. The CMDC data are particularly useful because they are provider-specific and timely — key ingredients to making quality improvement (QI) successful. As you can see in the graph below, the c-section rate at this facility started out at 33%, on par with the rest of California.
By raising the awareness of obstetricians at the hospital and making their individual rates transparent, the hospital was able to drop the c-section rate by 10 percentage points to 23% in only five months. This is a great example of using data to drive quality improvement, in real time, with benefit to mothers and families alike. Imagine what could be accomplished if the more than 250 California hospitals that deliver babies adopted a similar program?
NTSV C-Section Rate: The percentage of cesarean-section deliveries among mothers whose pregnancies were nulliparous, term, singleton and vertex (NTSV), which means the delivery of a single baby (versus twins or triplets) in a head-down position after 37 weeks gestational age to mothers having their first baby. The national target rate of 23.9% for such low-risk pregnancies was set by Healthy People 2020.
But Falling Short on Postpartum Care
If Dr. Main's talk filled me with hope, a data point from a presentation by Dr. Neal Kohatsu, the medical director of the California Department of Health Care Services (DHCS) stirred a different reaction. In his discussion about how the department is using quality improvement, Dr. Kohatsu showed the following graph, which highlights the percentage of women in the Medi-Cal program who receive timely postpartum care. (DHCS oversees the Medi-Cal program.)
Timely postpartum care is important to assure the mother that she is recovering well and to ensure she has the physical and mental health support she needs. For mothers in Medi-Cal, the rates range from a high of 52% among Latinas to a low of 33% among African American women.
This is an alarming disparity. The first weeks after childbirth are important for newborn and mother. Women who have recently given birth are at risk for abnormal bleeding, iron deficiency, and infections. In addition, postpartum depression is common. Postpartum screening is critical to assess these issues, along with the social and emotional support new moms are receiving from their family and community.
A DHCS quality improvement initiative aims to raise the percentage of African American Medi-Cal enrollees who receive timely postpartum care to 35%. That's laudable. But we need more. If one place is doing it better, let's find out why and see if their performance can be replicated.
With maternity care, as with so many other quality challenges in our health care system, the data are telling us something. We need to listen — then come up with a plan to act. The California Maternal Data Center has shown how data and leadership can achieve bold goals. Still, there is more to do.