In Cesarean Surgery

According to Kaiser Health News, Hoag Memorial Hospital, “one of the largest and most respected facilities in Orange County,” delivering more than 6000 babies per year, reduced its cesarean rate in just 3 years from “about 38%” to “just over one-third of all births” and to 27% in low-risk 1st-time mothers. “In medicine, this qualifies as a quick turnaround,” burbles the article’s author, “and the story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance.” Indeed, it does, but not in a good way.

For starters, was the reform because Hoag had seen the error of its ways? Not a chance, as you may have guessed from the fact that they’re still doing way too many cesarean surgeries. No, it was because “a big insurer had warned that its maternity costs were too high, and Hoag might be cut from the plan’s network.”

And how did they manage to shave a minimal percentage off their outrageously high cesarean rate?

To begin with, administrators revealed the OBs’ cesarean rates to each other—not to their patients, mind you; they’re still in the dark. The docs didn’t take kindly to this: “There was a lot of upheaval,” said one, “None of us wanted to look bad in front of our peers . . . and some looked horrible.” So it’s not what you’re doing, it’s someone else finding out about it. Another OB was worried that the rates would be used to penalize them. You mean, they shouldn’t? Doctors also blamed their victims: women were older, they had more complicated pregnancies, they “demanded scheduled C-sections.” I refer anyone tempted to swallow that line to Birth by the Numbers. And, of course, they “questioned how the numbers were gathered.” Not all the OBs were unhappy about the reveal. One said that being aware that Hoag is monitoring her cesarean rate has encouraged her to let women labor longer. Translation: I’m doing the right thing more often now because I’m being watched.

In addition, a business group working to bringing down California cesarean rates collaborated with the biggest local employers and another insurer, Blue Shield, to adjust payments so that the hospital didn’t get paid more for cesareans. Clearly, they understood what drives decision making at hospitals like Hoag. Nurses got in on the action too. They were asked to take cesarean prevention measures such as getting laboring women up and moving around. They got end-of-the-year bonuses for helping the hospital reach its goal. In other words, nurses, too, needed financial incentives to do what they should have been doing in the first place.

The hospital hired laborists as well, leading one doctor to comment that having in-house OBs available 24/7 allowed him to be “a little more patient.” Apparently, “impatience” is a legitimate indication for major surgery at Hoag.

The article closes with a feel-good story under the subhead: “Good for Patients Too.” A woman didn’t want a repeat cesarean, and thanks to Hoag’s new attitude, she “got her wish.” “I’m feeling really good,” she says, “This is how childbirth is supposed to be.” I’m glad for her, but you shouldn’t need to hold the hospital at metaphorical gunpoint to make it happen.

Presumably, the insurance company is off of Hoag’s back, and it’s a happy ending for all—except, of course, for the thousands of women per year who are still having unnecessary cesarean surgeries at Hoag and suffering the consequences and who have no idea that their care providers don’t care how many cesareans they do unless motivated by gain or fear.

“The data helped people achieve the culture change,” says the senior manager of the business group. Actually, the culture hasn’t changed a bit. No one cared about what was best for their patients, and they still don’t.

The medical director of the California Maternal Quality Care Collaborative comments, “Many hospitals don’t act until dollars are at stake,” adding that Hoag is now becoming a model for other hospitals. Sadly, he’s right.

I don’t know which is worse: the indifference of Hoag Memorial staff to the health and wellbeing of mothers and babies until there’s something in it for them or this article’s obliviousness to that fact. Hoag is a poster child for everything that’s wrong with the system, but no one seems to have noticed.

Learn more about preventing the preventable cesarean .

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