The surprising factor behind a spike in C-sections

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{***Noah***}

Coming up on Harvard Chan: This Week in Health.

What’s driving a dramatic increase in the world’s most common surgery: C-section?

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(C-sections in this country vary between 7% and 70% by hospital. It’s tenfold risk, depending on where you go)

In this week’s episode: The long-term risks posed by C-sections, and why the hospital where a woman gives birth may be the single most important factor influencing whether or not she has a C-section.

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Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, July 27, 2017. I’m Noah Leavitt. Amie Montemurro is off this week.

Cesarean delivery of a baby—or C-section—is the most commonly performed surgery in the world.

Rising C-section rates are a problem all over the world—but it’s particularly notable in the United States.

C-sections have skyrocketed in the U.S. since the mid-1970s. In just one generation, this country’s C-section rate has increased 500%.

One in three babies are now born via C-section—compare that one in 20 in the mid-70s.

And a mother who has a C-section for her first delivery is overwhelmingly more likely to have C-sections for future deliveries.

And while it’s incredibly common—it’s still major surgery—with a range of potential complications such as hemorrhage or infection.

It’s estimated that nearly half of C-sections may be avoidable—but to prevent them, researchers need to find out what exactly is driving the dramatic increase in their use.

That’s the focus of Neel Shah’s work. He’s the director of the Delivery Decisions Initiative at Ariadne Labs—and you’ll hear from him in just a moment.

Shah is an obstetrician-gynecologist—and his research has shown that the hospital where a woman gives birth may be the single most important factor in whether or not she has a C-section.

Coming up over the next 20 minutes—Shah will explain why that’s the case—and also what can be done to reduce a woman’s risk of having a C-section.

But first, I asked Shah to explain why we should be concerned about America’s high C-section rate.

NEEL SHAH: C-sections are very common. Everybody knows people who have had C-sections and they all seem fine, which is part of what’s so insidious about it. But when you look at them cumulatively, so major surgery comes with risk of complications immediately. So the risk of severe hemorrhage, bad infections like sepsis, organ injury, around three times higher with a C-section as compared to not having a C-section. But the real harm from C-sections actually accrues later, which is part of what makes it so insidious. So a first time C-section, I’m an obstetrician so I do a lot of them, and I can train a brand new intern, which is a lot of what I’m doing in July, how to do a C-section in a couple of weeks if it’s the first time. But we’re the only surgeons that cut on the same scar over and over again. And when you operate on somebody and then you go back, it’s not quite the same. So the second time you’re operating on someone, it’s a little more complicated. The third time it’s quite complicated. I often ask for a senior resident or a chief, because you know the worst C-sections I’ve done it’s like operating on a melted box of crayons. And that can be really, really harmful, because sometimes the placenta can get caught up in all of that scar tissue. The placenta is an organ that gets 25% of everything that the heart pumps. It’s a big bag of blood vessels. And in those conditions, it’s called a condition called placenta accreta moms can bleed very, very heavily and sometimes even bleed to death.

NOAH LEAVITT: So you’re seeing patients who will have one two three multiple C-sections over the course of their lives?

NEEL SHAH: Yeah, most moms have more than one baby. So a lot of what we’re thinking about now is actually how you prevent the first index C-section doesn’t need to happen because many moms are going to have other babies. And if you have a C-section the first time, the odds are right now in the United States that you will have a C-section, there’s about a 90% chance you’ll have another one.

NOAH: LEAVITT: And so, what percentage of the C-sections that are occurring in the US would you say or I guess medically necessary, that they need to happen to save the mother or the baby?

NEEL SHAH: Well hindsight’s always 20/20. That’s the whole challenge. When I do a C-section, it’s really easy to justify because I feel like I’m always right. We almost always do them for the baby; rarely do them for the mom. And if the baby comes out looking perfect and pink and squirming around, I think, hey, it’s a good thing I did a C-section. I totally won. And if the baby comes out blue and lackluster, I think, man, it’s a really good thing I did a C-section. So either way, it’s pretty good to be me because I’m always right. That being said, you know, we think at least half of the C-sections that we do are probably not necessary. That’s based on a bunch of different estimates. We don’t know what the perfect rate is, but we do know that the plurality, if not the majority of the C-sections that we’re doing currently are probably avoidable.

NOAH LEAVITT: And so you touched on a few minutes ago the fact that really in a generation there’s been this dramatic spike in C-sections, so what are some of the factors that are driving that?

NEEL SHAH: Noah, what’s almost more interesting than that question is what’s not driving it. Because there’s so much conventional wisdom about what’s going on. Like when you look back at the ’70s, you’re like, oh, the moms looked different. You know there is more obesity and hypertension and diabetes now. Moms are older than they used to be. Turns out all those demographic shifts actually explain surprisingly little. And the reason is that C-sections have gone up an 18-year-old just as fast as they’ve gone up and 35-year-olds. And there’s still more 18-year-olds having babies than 35-year-olds. So demographics doesn’t really do it. Reimbursement policy doesn’t explain it very well. Because even during areas where people have been paid the same, the rates continue to go up. Malpractice doesn’t explain it very well because even while malpractice has stayed the same, the rates have gone up. And even like women’s preferences don’t explain it very well. Turns out less than half a percent of moms like request these surgeries electively. So it’s none of the things that most people assume it is. We have a more nuanced explanation for what might be going on, which has to do with the complexity of the delivery environment. So it turns out like, you know your grandparents were born at home. It was a pretty simple environment usually involving a bed and that was pretty much it. We made a lot of advances by bringing people in the hospitals, but it’s a relatively recent phenomenon. It wasn’t until the middle of the last century that really people start coming to hospitals in droves. And then what that hospital environment looked like has changed dramatically. And we now deliver 99% of our babies in these environments that basically look like ICUs. That’s part of what different. If we think about it, you take a healthy mom, you put them in the ICU, and you surround them by surgeons, you’ll get a lot of surgery.

NOAH LEAVITT: So as part of the Delivery Decisions Initiative I mean I’m guessing one of the things you’re doing is kind of taking a look at this environment. And I guess I, mean is part of the goal is seeing what can we change in those delivery floors that might lower the C-section rate?

NEEL SHAH: Yeah. I mean we’ve taken this approach where you know, these environments are extraordinarily complex. So it makes it an ICU, it’s not a ventilator that defines an ICU. It’s the ability to have one nurse take care of one patient. So if you go to the cardiac ICU of my hospital at Beth Israel, you’ll see one nurse per patient. You go to my labor floor, you’ll see the same thing. You know they can track vital signs in real time in the cardiac ICU. So can we. The only difference between the ICU and the labor floor is that our operating rooms are attached. So we actually have the most intense treatment environment for what are probably the healthiest patients in the entire hospital. And when you look at the problem that way, one of the things that you realize is that us overdoing it in health care might be a product of the complexity of the environment. And what that means is, often when people try to understand why we’re doing too many C-sections, they assume that you know fixing the incentives, which underneath that that means that people are doing it on purpose. But I actually think that the C-section problem is due to unintentional errors, like so many of the errors we see in health care. Because basically you can mess up two ways, by doing too little and by doing too much. And so a lot of what we’re doing in the Delivery Decisions Initiative is trying to take that starting framework, like what if people are doing too many C-sections but they’re not doing it on purpose.

NOAH LEAVITT: So in a sense it’s because this infrastructure in a sense has been built out in a kind of, I guess knowingly or unknowingly, drives people towards wanting to perform, not wanting to perform surgery, but it drives them towards performing surgery.

NEEL SHAH: Totally. Yeah. We know that we’re going to err, so we err on the side of doing too much without seeing all the harm we’re doing.

NOAH LEAVITT: And so when it comes to, I mean you mentioned that like the labor floor in a sense has become like an ICU, so what drove that? I mean how did hospitals become more complex? Is it just because of new technology and new medical advances made it necessary? I mean what’s been driving that change?

NEEL SHAH: There have been a few index technologies I think are partially responsible for it, for example, the ability to track fetal heart rates in real time. When that technology gets introduced, it saturates the market very, very quickly, meaning everybody’s using it. It requires a lot of monitoring and documentation of the patient. The only thing it does reliably is increase C-section rates. It was designed to make babies better off. It does not do that. And the technology is impossible to get rid of even though this is the effect. We’ve been using it the same way in the ’70s, ’80s, ’90s, 2000s, and 2010s. So that’s part of it. I think another part of it is just the challenge. One of the things that makes childbirth unique is that you’ve got this patient dyad. Right you’ve got the fetus and you’ve got the mom. Sometimes their interests are really well aligned. Sometimes we think that those interests are in tension. And when we think that interest are in tension, the baby wins.

NOAH LEAVITT: So can you give an example of that kind of like playing out?

NEEL SHAH: Yes. Sure. I mean, the big picture is that we’re doing all of these major surgeries on moms which are causing hundreds of thousands of cases of unnecessary suffering. But the babies mostly look OK. And so if there’s any question that the baby could be compromised in any way, then we will go to these great lengths, to the point of performing major surgery on the mom. But the thing is in reality it’s often a false choice though. And you know there’s with these tensions there’s always a question of to what degree are we willing to do this? And right now my concern is that we might be hurting the healthy majority of moms in the interest of trying to make the risk as low as possible for the sickest of people.

NOAH LEAVITT: And is one of the factors, I mean is, because you are someone who is an OBGYN, when you’re maybe talking through this with the mother, I mean they’re probably on the side of almost do whatever it takes to help the baby. So that kind of a factor in this, that people are like you said, are kind of, no matter what, it’s about the baby. And the mothers, I mean, I don’t if I want to use the word selfishly. The mothers are not going to be thinking selfishly.

NEEL SHAH: Yeah, no. I think that’s right. I think moms have limited agency when they’re in labor for so many reasons. One is that I think that they feel very responsible for the well-being of their fetus or their baby. But I think part of it also is that, there’s just a dynamic where even if a mom comes in very committed to laboring, you’ll defer to your doctor. And I think the doctors are also very well-intentioned. But when they recommend a C-section there’s not a lot of accountability.

NOAH LEAVITT: And so you talked earlier about the kind of growing complexity of the delivery process. So your recent study looked at how hospital management practices influence risk of someone having a C-section. So I guess what was the kind of question you were looking to answer and what did you and your team find?

NEEL SHAH: Well, I delivered babies at three Boston hospitals when I went from training to becoming a member of the faculty. And all these hospitals, Boston as you know is a fairly small city. So they’re within three miles of each other. They take care of pretty much the same patients. And I realized that it could feel like a lot more work to me to take care of the same patient, depending on which hospital I was in. And that was interesting to me. Because at the end of the day the C-section is like a rip cord. It’s like your way out. It’s your way out of the uncertainty. It’s your way out of the effort of trying to manage a complicated labor. And I thought maybe if there are certain places where it’s harder to take care of a patient, you might be more likely to do the C-section prematurely. That was the theory that started it. We also noticed that in 2017 your biggest risk factor for the most common surgery is which hospital you go to. C-sections in this country vary between 7% and 70% by hospital. It’s tenfold risk, depending on where you go. And there are parts of our country, Miami-Dade County, lots of Southern California, where within the same zip code, like literally, it’s like multiple times risk depending on which hospital you go to. So that bothered me. That seemed wrong. And we just wanted to understand why. What is it about the hospital that makes the hospital a big independent risk factor? And so we keyed in on this idea that management matters in health care and childbirth just like it does in every other industry.

NOAH LEAVITT: And so when we’re talking about manager practices, I mean you touch on the fact that you can give birth, that you could deliver a baby in three different hospitals, and one could feel like much more work than the other. So what are the factors that make delivery feel like it’s more work? What are the management practices that influence that?

NEEL SHAH: Yeah. So this is really complicated to unwind as you can imagine. And we identified 16 different factors that managers have some influence over that could impact us. And they don’t work independently. You can be really good at managing one thing and it can make up for being really bad at managing another. But one of the fundamental challenges of a labor floor is you don’t really know when your customers are going to show up. Like if there’s a full moon, a lot of people go into labor. That’s been my observation. And then once they show up in labor, you don’t know how long labor is going to take. It’s different for every patient, and it can vary dramatically. And then you don’t know which one of those patients is going to become sick enough to need a blood bank or operating room or some kind of critical resource. So if you’re managing all that, you’ve got all that uncertainty, and you have to figure out which nurse goes to which patient and which patient goes to which room and you have to like shuffle the deck every once in a while. And like that in particular seems to be one of the most important things, how nurses are assigned to patients, when that gets updated. And then we looked at other things like patient flow, you know, if there’s a certain part of the labor unit that’s getting backed up, how do you solve for bottlenecks? How does the team communicate with each other and collaborate, things like that.

NOAH LEAVITT: And so I find that interesting because the factors influencing a medical procedure don’t really seem like they’re medical things at all they’re much more infrastructure and organizational. So I mean I guess, and this is one of the questions that you’re looking to answer, but I mean what would an ideal labor floor look like then going forward?

NEEL SHAH: We’ve looked at this in a bunch of different ways. We’ve brought architects on labor floors who study them from a management lens. But if you think about it, and then everyone who works on the labor floor realizes that the care that a woman gets depends not just on how they’re doing but how everybody around them is doing. Which is, a woman who’s in labor you rarely have insight into. You’re in your labor room, but you don’t know what’s going on outside. But if you were to get onto the highway, usually you try to avoid a high traffic moment. And we have good evidence from this study and others that we have done that high traffic on the labor floor, particularly about the ability to manage it well can be a risk factor for moms. I think what we see is an opportunity to intentionally simplify some of this complexity. Like if you think l it, in every other aspect of our lives, that’s what science’s purpose is, from the way we get around, to the way we put food on the table, the way we communicate. Science is meant to simplify our lives. Health care does the opposite because every time we have a new capability, we just deploy it without thinking about how it’s going to fit in. And so what we’re doing is we’re analyzing every part of caring for women in labor. And we’re looking for opportunities to just make the decisions a little bit more simple. And often what that involves is taking a lot of the tacit decision making and making it explicit, and then just showing people the boundaries of appropriateness. For example, we know that in the first phase of labor, which we call the latent phase of labor, there are actually zero reasons to ever do a C-section for labor progress. Which is really helpful because zero targets in health care improvement are the whole ballgame. Right, like you know you want a zero mortality, which is why mortality is easy to go after. You don’t know what C-section rate you want ideally, and it’s definitely not zero. But in this one phase of labor, it is zero. And so we’re like keying in on that and like using that as a leverage point for example.

NOAH LEAVITT: And so knowing that about that early stage of labor, is there any kind of lessons you can then learn about later stages of labor?

NEEL SHAH: Oh absolutely, yeah. And we’re sort of applying it down the line. So one of the things we’ve noticed is that in labor you know there are all these recurring assessments that we make of women. Like every couple of hours we go in, we check in on the mom, we check on the baby, we check in on labor progress. But a lot of the way that we make those assessments and then communicate them is tacit, unstructured, and unreliable. And that’s what we do here at Ariadne labs. We try to think about how to make them explicit and structured and reliable. And so that’s what we’re up to.

NOAH LEAVITT: And so I want to quickly touch on one of the things you mentioned earlier, how it’s almost like you know, you’re jumping on the highway, you’re going to avoid the high traffic area. So from the doctor’s perspective, I guess one, what would be high traffic for an OB on the labor floor, but also like as a doctor, how does that kind of play into your decision making. Maybe you’re juggling four or five patients at once.

NEEL SHAH: Your textbook teaches you how to take care of the patient directly in front of you. Being a good obstetrician is not about taking care of the patient directly in front of you only, because usually you have a couple women in labor that you’re responsible for. You also have women in other parts of the hospital that you might be responsible for, the emergency room, the postpartum unit, you might be getting pages from patients at home. So you’re sort of juggling all of those things. I mean, so often it’s not a conscious thing. But you know, we’re constantly managing uncertainty on the labor floor. The most common reason to do a C-section United States is for what we call failure to progress, which is basically labors are taking much longer than average. So you can imagine that if you have three patients that you’re caring for and you’re totally out of beds on the labor floor. Every bed is full. And you really need to make a bed available. And one woman is taking much longer than average. And you believe in your heart that ultimately she’s going to need a C-section anyway, you might do it an hour earlier than you absolutely have to. But the truth is in obstetrics, we never know. And there is many times where people eke it out.

NOAH LEAVITT: And that’s an interesting example. That’s kind of a confluence of everything you’re talking about, where you have the shortage of beds, so there’s an infrastructure issue, and then there’s kind of as a doctor, you’re juggling all the different patients. That’s the most common reason for a C-section.

NEEL SHAH: That’s right and this is the complexity. Because the doctor is juggling all this stuff, as is the nurse and the managers of the unit. And the way that we juggle all this stuff is highly informal right now. It’s not structured. It’s not reliable. And like we basically learn how to do it through an apprenticeship. But we haven’t really– there’s no textbook on how to do this. So part of it we’re trying to do is figure out how we can take key parts of it, structure it, in ways that make people safer.

NOAH LEAVITT: So for mothers, for the patients, I mean this seems like it’s probably a conversation that should start early in the process. So do you recommend that people actually sit down with their doctor and say, you know, when it comes to having a C-section, these are the situations where I’d like to have one. Is this a conversation that should start early in the pregnancy?

NEEL SHAH: I think so. I mean I think it’s very important to have a clinician of course that you feel comfortable with, that you have a good relationship with, that you can assert your preferences with. There are so many things in pregnancy and childbirth that are legitimately preference sensitive. And you know, that being said, and you know I think there’s a role for something like a birth plan, which is designed ultimately to do very similar things like a living will, just basically to express her preferences and then get us in the health care world to dial it down a little bit.

NOAH LEAVITT: It’s the complete opposite end of the spectrum. But it sounds a lot like the conversations about like terminal illness, like having the conversations well before the time comes.

NEEL SHAH: Well, if you think about it, Noah, I mean birth and death are life’s only few certainties. We’ve institutionalized both actually relatively recently. And we’ve erred on the side of overdoing it in both cases. So there are a lot of parallels there.

NOAH LEAVITT: Interesting. As a doctor yourself, as you do this research, does this play at all into the decisions you’re making on a day to day basis or is a lot of times are things happening so fast that you kind of have do have to sit back and look at things with hindsight to really analyze the decisions you made?

NEEL SHAH: Well both are true, to be honest. Like I don’t know what my own C-section rate is until somebody tells me, which is the challenge of being a clinician in the trenches. You just don’t have the optics to have a fully baked sense of the consequences of your actions except for the most immediate things that you see. So one of the great opportunities. I have from both being a clinician and working here at Ariadne Labs is I have this chance to kind of step back and you know look at the whole system.