Research has long established that hospital-level cesarean rates vary widely for reasons that cannot be explained by variations in their patient populations. Theorizing that the challenges of caring for an unpredictable number of women with unpredictable and rapidly changing care needs on low financial operating margins might play a role, a group of investigators decided to examine whether labor & delivery unit management practices could be a factor. Let’s see how they went about it and what they found.
Drawing on the obstetric research and the advice of experts, the investigators developed a list of systems and management strategies that could affect cesarean rates. They incorporated the list into a structured interview of nurse and obstetrician managers and assessed associations between unit practices and the percentage of low-risk women having first cesareans. They conducted interviews at 51 U.S. hospitals across the country and obtained outcomes data on 227,463 eligible women (one, head-down baby, at 37 wk gestation or more, no prior cesareans) delivering at these hospitals. Hospital characteristics were diverse, although they skewed toward larger annual delivery volumes and more women with risk factors than the national average. Two-thirds of participating hospitals were teaching hospitals, and two-thirds had a midwifery service.
Analysis identified three strategy clusters, two of which were associated with increased cesarean rate:
- Unit-culture management strategies: team collaboration in making care plans, communication and coordination within and across disciplines, obstetrician availability when needed, shared accountability among obstetricians for patient outcomes, staff engagement with and monitoring of quality improvement, optimization of timing of admission, commitment to vaginal delivery
- Nursing management strategies: communication and management of disagreements about patient care, methods for assigning nurses to patients and reassessing as needed, strategies for adjusting nurse staffing to manage capacity constraints
- Patient-flow management strategies: monitoring number of patients and intensity of care needs to anticipate staffing needs, tracking and anticipating bottlenecks in patient flow, adjusting physical capacity to accommodate need, methods for scheduling planned deliveries
Before we go on, would you expect proactive management hospitals, that is, hospitals that scored high in having these management strategies in place, or reactive management hospitals, that is, hospitals that scored low, to have higher cesarean rates?
To the investigators’ surprise—they described it as “counterintuitive”—after adjustment for maternal demographic and clinical differences and hospital differences, low-risk women delivering at the hospital with the highest unit-culture management score were 30% more likely to have a first cesarean than the hospital with the lowest unit culture management score, and women delivering at the hospital with the highest nursing management score were 47% more likely than the hospital with the lowest score. Patient-flow management scores, on the other hand, had no association with cesarean rate. No associations were found between occurrence of severe maternal morbidity or infection and any of the management clusters.
What could explain this? The investigators propose several theories: It is possible that hospitals with higher cesarean rates instituted more proactive management practices in an effort to bring down their rate. This seems the most plausible, considering the nature of the unit culture and nursing management strategies. Other possible explanations, though, are not so benign: “Managers may face competing management goals that do not optimize cesarean delivery rates such as enhancing financial performance,” for one, and, noting that larger hospitals and teaching hospitals tend to care for sicker women, “Management may be optimized to care for the highest risk patients rather than lower risk patients within these settings,” for another. And, of course, there’s no reason why more than one factor couldn’t be in play.
Whatever the underlying cause, this intriguing study adds to the evidence that cesarean rates are driven by systems factors that can and should be modified. Furthermore, it seems likely that non-medical factors would play an even bigger role in hospitals that have no midwifery service to act as a counterweight to typical obstetric practice or where hospital administrators actively pressure managers to improve their unit’s bottom line.
The Take-Away: This study makes clear that while individual care provider cesarean rate matters, so do overall hospital rates.