This article was adapted from a post published on the Health Affairs Blog on November 2, 2015.
Birth is universal, and because of this fact, it is also a big health care issue. Childbirth is the number-one reason for hospitalization in the United States. The stakes are high, both from a health and a cost perspective. It is the only procedure that begins with one patient and ends with at least two. And at about $15,000 to $20,000 per birth, it is an expensive proposition. Additionally and importantly, birth is a compelling Medicaid issue, because nationwide, the program pays for half of all births.
Within the topic of maternity care, cesarean section (c-section) figures prominently, especially in the US, where the rate is one of the highest among industrialized nations. The US c-section rate has risen 50% over the past 15 years, according to the California Maternal Quality Care Collaborative (CMQCC). (CMQCC is a multi-stakeholder group that drives improvement in maternal and infant outcomes through rapid-cycle data analytics and collaborative action.) One-third of all babies born in this country enter the world via surgery — a significant departure from the federal Healthy People 2020 goal of 23.9% for low-risk deliveries.
Why Are High Rates an Issue?
Overuse of c-sections matters because, while these surgeries are critical and often lifesaving in limited circumstances, they also bring serious risks for both mothers and babies.
For the baby, c-sections are associated with higher rates of infection, respiratory complications, and neonatal intensive care unit (NICU) stays.
For mothers, c-sections often mean higher rates of hemorrhage, transfusions, infection, blood clots, and postpartum depression. Mothers having undergone a c-section also have a longer recovery and have a greater than 90% chance of a repeat c-section in subsequent births — leading to higher risks of major complications (for example, hysterectomy, uterine rupture). Also, to the detriment of both mother and baby, breastfeeding rates are lower following c-sections.
On the cost side, c-sections are on average $5,000 more than vaginal births, not including associated costs (for example, hospital readmissions, home care, subsequent c-sections), according to CMQCC. When one considers overall US health care spending, that may not seem like much. But with tight Medicaid budgets, and about 4 million total US births annually, it adds up. The bottom line: c-sections are an important tool — but one that should be used sparingly.
Moving Toward a Solution in California
In California, where 500,000 babies are born each year — one-eighth of all US births — an effort is afoot to lower the c-section rate. Focusing on first-time, low-risk deliveries (another way of saying "low-risk" is "NTSV," or nulliparous, term, singleton vertex), many stakeholders across the state are recognizing the importance of this issue and are starting to take action. These stakeholders are spurred on by the fact that there is striking, unwarranted variation in the c-section rates for low-risk deliveries. These vary from 12% to 70% across California's 251 hospitals providing maternity care. This variation means that a woman's method of birth can by affected simply because of the hospital at which she delivers — that is, for no evidence-based reason at all.
Although troubling, this variation also signals an opportunity: Although 60% of California hospitals need to improve to hit the national target, 40% of hospitals already meet the goal, showing that achieving that goal is possible. Also, a recent successful pilot in three Southern California hospitals led by the Pacific Business Group on Health (PBGH) underscores cause for hope (PDF). These hospitals reduced their low-risk c-section rates by about 20% in six months and, notably, have maintained their lower rates since.
How was this reduction accomplished? It took pulling several key levers (depicted below). Through the innovative, low-burden, low-cost Maternal Data Center run by CMQCC, these hospitals were able to determine their c-section rate and also drill down in the data to get physician and patient information, which is very helpful in understanding the drivers of the overall rate. CMQCC also showed providers how to improve quality of care.
Purchasers — such as Disney — signaled dissatisfaction with their employees' high c-section rates. The contract requirements and payment methods that followed aimed to put in place one "blended" payment for a delivery of either type versus paying more for c-sections, which is now often the case.
Likewise, patients helped the cause: Negative social media about high c-section rates at one hospital got the attention of administrators.
In the background, public policy was hinting at change: Legislation was being considered to allow midwives — whose goal is supporting vaginal birth — to practice at the top of their license.
What happened in these pilots serves as a good model. Not all of the levers have to be pulled to make measurable change, but several are certainly needed. And the more levers that are pulled, the more accelerated and sustained the change can be.
Building on Success
As part of its emphasis on high-value care, CHCF has launched an initiative to lower the state's c-section rate for low-risk women to 23.9% in five years. The foundation is funding projects to pull as many levers as possible, as simultaneously as possible, to bring about change — building on statewide momentum by working with many engaged partners, including CMQCC, PBGH, California Department of Health Care Services (DHCS/Medi-Cal), Covered California, Integrated Healthcare Association, California Public Employees Retirement System (CalPERS), Hospital Quality Institute of the California Hospital Association, and both state and national specialty provider societies. Notably, Smart Care California (formerly the Statewide Workgroup on Reducing Overuse) — a multi-stakeholder group led by CalPERS, DHCS, and Covered California that purchases and/or manages care for 15 million Californians — recently selected c-section reduction as one of its three goals.
Building on its early investment in the Maternal Data Center, CHCF is providing continued support for this critical transparency lever, as well as for development of a c-section toolkit for providers and a statewide quality improvement initiative to implement the toolkit in at least 60 hospitals. CHCF also anticipates funding projects to engage patients and support payers.
It is possible to lower the c-section rate. And knowing what we do about the health risks and costs, we have an imperative to eliminate overuse. With strategically placed funding, CHCF aims to contribute to moving the needle. We hope to be reporting success in a few years, thus giving California more reasons to celebrate its 500,000 annual births.