OHSU Team Looks to Reduce the Number of C-Section Births
March 15, 2012 – Last month 21.7 percent of the babies born at Oregon Health & Sciences University were delivered via Cesarean section – slightly fewer than the number of C-section births statewide (28.2 percent in 2008) and lower than the national average of 32.3 percent (also in 2008), according to numbers released by the March of Dimes.
“That was a one-month number that happened to be low,” said Dr. Aaron Caughey, the director of OHSU’s Center for Women's Health. But that number does reflect an effort to curtail the number of C-section births at OHSU.
When Caughey lectures the medical staff, he encourages them to talk to women about vaginal births after they’ve had a C-section, realizing that some complications (such as breech births) can be handled without the surgical intervention.
“We're not saying to every single person -- here's a guideline -- you have to do these things,” Caughey said. “You have to change the culture.”
That might explain OHSU's success in increasing the number of vaginal births. About 18 months ago, Caughey and his colleagues began holding weekly conferences to discuss birth statistics for the previous month, talking to OB/GYNs, midwives and family medicine doctors about each C-section, why it was performed, then they discussed alternatives.
That discussion alone “makes individual clinicians think twice before they pull the switch on the C-section,” said Caughey. “We thought about giving people their individual numbers,” but since each clinician only attends such a small number of births each week, one C-section – which may have been completely necessary – can have a huge effect on that clinician's percentage. “It's better to talk about people's annual delivery rates.”
It can also be unrealistic to single out an individual clinician since members of OHSU's team relieve each other – so on a particularly busy night, an OB/GYN may attend several patients with complicated labors if the midwifery team is busy.
Observing and discussing birth results at a larger level activates what Caughey calls the Hawthorne Effect – where people change their behavior when they know they’re being observed.
Nationally, C-section rates peaked in the 1980s at about 26 percent in the U.S. – the highest of any country in the developed world. By 1989, that number had dipped to 22 percent – the only time an industrialized country had lowered its C-section rate, Caughey said.
While C-section rates have steadily climbed since then, advocates who believe there should be fewer medication interventions have been successful influencing first-time mothers to have a vaginal birth and also those who’ve had a C-section.
“The C-section rate in your first pregnancy matters a ton,” Caughey said. “The C-section rate is only about five percent of women with a previous delivery.”
On the other hand, the rate of vaginal births after C-sections (VBAC) is very low – frequently because women are coerced into having a second C-section after having the experience, Caughey said. That’s why clinicians have taken the two-pronged approach of encouraging women who’ve had a cesarean birth, as well as first-time mothers, to consider giving birth vaginally.
Liability issues have also affected the increase in C-section births, as well as a general cultural trend toward instant gratification and a low tolerance of bad outcomes. Some hospitals, for instance, won’t perform a VBAC birth since it's easier to just perform a scheduled C-section.
“We're trying to head in the right direction,” Caughey said. “Many people feel like the rate is probably above where it needs to be to be safe.”