OHSU Team Looks to Reduce the Number of C-Section Births

Discussing birth outcomes on a week-by-week basis may account for the dip in C-section births
The Lund Report

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.”

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Comments

Another issue not mentioned is premature induction of labor. Many C-sections would be avoided if physicians were willing to support their patients in waiting until the baby is ready to be born instead of inducing at an arbitrary number of weeks. Of course, there are real medical indications for early induction of labor, but merely having the baby's gestation exceed 38 or 39 weeks is not one of them. Add to that the practice of using ultrasound to estimate due dates, instead of using the more reliable date of conception or date of last menses, and we end up unnecessarily inducing a lot of labors with neither the mother nor the baby ready for delivery. It should not surprise anyone that early induction leads to more C-sections, so part of reducing C-secs has to be eliminating unnecessary induction of labor. Nature is pretty smart. People have been giving birth for tens of thousands of years on nature's plan. Sure, there are times when nature needs an assist, but most of the time, if left alone, the baby comes out when the baby is ready, and that works a lot better for the mom, the baby, and the family. We'll have less C-sections the more we allow nature to take its course, and intervene only when the safety of the mother and baby demand that we do.

Thank you sooo much for making that comment. I was one who was pushed to have my second baby earlier then I knew she was due because the ultra sound put her as due July 16th but I knew the baby's due date was closer to the 28th based on implantation dates. Sure enough my baby wouldn't eat and wouldn't even wake up acting hungry. Luckily she is thriving now but it was the scariest thing I have ever experienced.

Thank you Lund Report for providing this important coverage. OHSU is setting a good example that can and should be replicated in other facilities. That said, I am curious to know where the statewide c-section statistic of 23.4 came from? This is SIGNIFICANTLY lower than the 29.4 statistic for c-sections reported by Oregon Public Health Authority in 2010. I blogged on this last year: http://motherbabynetwork.wordpress.com/2011/04/27/c-section-rates-for-lane-co-hospitals-other-hospitals-counties/ OPHA 2010 c-section statistics http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/birth/Documents/facilcesarean10.pdf In July 2011, The Oregonian reported a statistic of 29.82 http://www.oregonlive.com/health/index.ssf/2011/07/c-section_rates_in_the_us_reac.html

Thank you for commenting. I've corrected the story to reflect more recently published statistics and have included a link to my source.

As an obstetrician, I would love to lower the induction and cesarean section rate. Unfortunately I and many of my colleagues are pressured by patients to induce early. This trend was NOT completely arbitrarily started by physicians. Medicine has unfortunately become more consumer driven, which has some positives, but does put the physician in the middle. Add to that a plethora of satisfaction surveys and much of the drive to do the right thing becomes blurry and difficult. And heaven forbid I refuse to do a induction at 40 1/2 weeks and there is a bad outcome. To the poster above, the 38-39 week inductions I have seen in my career have essentially all been patient, not doctor driven (unless there is a good medical reason). The new standards that hospitals are creating to NOT induce before 39 weeks is applauded by MDs that I know, because it gives them a great response to the demanding patient. And for those who want to respond that the job of the doctor is to do the right thing-not just listen to the patient-if it were only that simple.