Cesarean sections are the most commonly performed surgical procedure in the United States, and more than a third of them are performed unnecessarily. The rate of c-sections performed without a medical indication (also known as low-risk c-sections) varies widely across hospitals, from 4.6 to 46.9 per 100 deliveries, according to the Agency for Healthcare Research and Quality.
Why do some hospitals have such a high rate of low-risk c-sections? Some say it’s a lack of awareness on the part of obstetricians in high-rate hospitals, who may not realize they are performing too many c-sections. Others attribute variation to differences in medical culture between hospitals (automatically performing c-sections on babies of a certain weight, for example). But one factor that had not been explored was the effect of hospital management practices on low-risk c-sections – until now.
After three years of interviews, site visits, and analysis researchers from the Harvard T.H. Chan School of Public Health have released the results of their research on hospital management practices and maternal outcomes. The researchers interviewed physician and nurse managers at 53 hospitals about their management styles and practices, and then compared maternal outcomes at these hospitals, controlling for demographic and other factors.
They found that hospitals that had more team collaboration and communication, staffing flexibility, and labor floor efficiency had greater rates of low-risk c-sections, compared to hospitals with lower unit management scores. These hospitals also had greater rates of postpartum hemorrhage, blood transfusion, and prolonged hospital length of stay.
However, not all management strategies had poor results; hospitals with dynamic resource management and flexible physical capacity had lower rates of low-risk c-sections.
At first glance, these results make no sense. How can better team collaboration, communication, and efficiency lead to worse maternal outcomes when some of the most successful programs to reduce unnecessary c-sections rely on clinicians following guidelines and anticipating problems?
The answer might be that management practices are increasing efficiency, but in pursuit of the wrong goals. Dr. Neel Shah, one of the study authors, suggests that clinicians at hospitals with proactive management practices may also face pressure to conduct more c-sections to meet financial goals or avoid risk. “While focusing on neonatal outcomes, financial performance, and other goals, we must question if we are taking our eyes off of the well-being of the mother,” said Shah.
For right care in deliveries, we need not only effective management practices, but also financial incentives aligned toward maternal health rather than unnecessary procedures.