This post is part of “Inequities in Maternal Mortality in the U.S.,” a blog series hosted by the MHTF.
When it comes to childbirth, the United States of America seems to combine the problems of the third world and the first world into a perfect storm. On one hand, 50% of U.S. counties lack a qualified childbirth provider. No midwife. No obstetrician. No family medicine doctor that delivers babies. In broad swaths of the country, women routinely drive several hours to get to a hospital with a maternity ward. And that’s when the #firstworldproblems kick in.
Even rural community hospitals in the United States brim with relative abundance. Typically, there is at least one nurse per patient in active labor. Multipaneled telemetry screens cover the walls to display fetal heart rates in real time. Each room is equipped with an infusion pump to precisely titrate medicines on a minute-to-minute basis. Wires and monitors are everywhere. If you didn’t know better, it would look a lot like an intensive care unit (ICU).
As it turns out, the only functional difference between an ICU and a modern labor floor is that most labor floors usually contain their own operating rooms. This means that generally speaking, the hospital’s most intense treatment area cares for its healthiest patients.
Currently, childbirth is the most common reason for hospitalization in the United States, and cesarean delivery is now the most common major surgery performed on Americans (one out of every three births). At the same time, nearly half of cesareans performed in the United States appear to be unnecessary with significant consequences for the safety, affordability and experience of care. National overuse of cesareans comes at a cost of $5 billion annually in excess spending and 20,000 avoidable major surgical complications in new mothers each year. Moreover, cesarean delivery rates vary tremendously across the United States, between 7% and 70% by hospital.
In recent years, patients, payers and other stakeholders have endorsed cesarean utilization for low-risk women as a key childbirth performance measure. Overuse of cesareans is harmful in itself and also provides a strong signal of overall quality of care. Hospitals with higher than average cesarean rates also tend to have higher rates of obstetric infection, hemorrhage and other related adverse outcomes. But despite long-standing recognition of the need for improvement and significant effort to report variation in these outcomes, maternal morbidity and mortality in the United States has been continuously getting worse for the last twenty years.
One reason why previous improvement strategies have had limited effect may be that variation in childbirth performance appears to be primarily driven by unaddressed hospital-level factors, rather than by the clinical factors or regional policies that are traditionally targeted. Currently, the specific hospital a pregnant woman goes to is a stronger predictor of whether she will end up getting a cesarean than her clinical risks or personal preferences. Local reimbursement and medical malpractice policies are also surprisingly poor predictors of cesarean use.
To improve care for mothers and newborns in the United States, our research team at Ariadne Labs has spent the last year trying to understand key differences between hospitals that may explain these wide differences in performance. The answers are not obvious, but we’ve started to uncover promising clues. In our early work, we discovered that hospital labor and delivery units are uniquely complex clinical environments that pose unique resource management challenges. In fact, that is an understatement.
Managing a labor floor may be the most challenging job in all of healthcare delivery. Despite functioning like an ICU (with all of its incumbent costs), labor floors receive a fraction of the reimbursement and are almost always financial loss leaders. Labor floor managers are therefore frequently working with constrained resources, and few things cost more than waiting patiently for a vaginal delivery. Managers also face considerable uncertainty at all times. They have very little idea when a new patient will show up in labor, how long labor will take, or when a seemingly healthy patient will become sick and require acute intervention.
Given these challenges, we have found that medical directors and nurse managers employ a wide set of strategies with variable effectiveness in order to safely monitor and support their census of laboring women. We have been fascinated to find that currently, very few managers are aware of how their counterparts solve the challenges they face. Over the next year our goal is to help provide this understanding, by simply describing what managers at high-performing hospitals are doing differently from managers at low-performing hospitals.
Photo: “Birth.” © 2015 Parentingupstream, used under a Creative Commons CC0 license.