Today’s Managing Health Care Costs Number is 34%
Cesarean section rates in the US have increased to about 34%. That’s much higher than in most of the developed world, although lower than in South America. The World Health Organization has long stated that the optimal CS rate is around 15%, and an article in JAMA this week shows that the “optimal” rate (which affords the lowest maternal and neonatal mortality and complication rate) is about 19% So we have a long way to go.
I’ll post more on the JAMA article in the coming days, but I wanted to point out that there REALLY ARE things we can do to lower Cesarean section rates. I’ve written before about South Carolina, where Medicaid and BCBS of SC both stopped paying for unindicated early elective deliveries. No surprise – hospitals and doctors stopped doing early elective deliveries.
Malini Nijagal, an obstetrician getting her MPH at Harvard this year, participated in and reported on an important natural experiment in Marin County where she practiced until this year. The county, just north of San Francisco, has a single hospital, and that hospital historically had two maternity services. The “public” service, which served largely the uninsured, had an active midwifery service and the hospital labor and delivery floor was covered by dedicated obstetricians (laborists) and midwives. The “private” service did not have midwives, and obstetricians covered their patients from home or the office. You can see below the dramatically lower rates of intervention among the (poorer) patients whose providers were on the L&D floor in shifts. But that’s not enough to convince us that this is a better way to care for new moms – because there are plenty of differences between private, insured patients and public patients lacking insurance.
This chart is data from an article she and colleagues published in Am J Ob Gyn earlier this year.
The two maternity services merged in 2011 – and the laborist/midwife service became the standard of care for both the private and the public patients. Nijagal and her colleagues looked at the CS and VBAC rates among just those patients with private insurance after the change. Voila. The private patients had dramatic decreases in CS rate and increases in VBAC rates after this change.
This chart is data from an article she and colleagues published in Obstetrics and Gynecologyin October
Public policy and public health experts have sounded the alarm about our increasing CS rate for decades. Meanwhile, groups of providers – backed by real data – are proving that they can make a real difference in CS rates.
We need payment reform to support those trying to improve maternity care. The resource costs of labor and delivery for vaginal births are considerably higher than the resource costs of CS deliveries – so paying facilities more for CS makes it hard for them to redesign their processes to increase vaginal births. Payment reform will provide much-needed support for the committed obstetricians and midwives who are continually improving care (and measuring their results) already.
