Delivery Decisions Initiative

Partners: Rx Foundation

Study results: Obstetrics and Gynecology, Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes, August 2017

This study of 53 hospitals found that certain management practices in labor and delivery units were associated with higher rates of cesarean deliveries and complications, independent of women’s health.

Researchers interviewed 118 nurse and physician managers at 53 diverse hospitals about three areas of management:

1. unit culture management, including practices that facilitate communication and collaboration among staff;
2. nursing management, including practices that ensure appropriate nurse staffing levels;
3. patient flow management, including practices that adjust resources to accommodate surges in patient arrival.

Hospitals were categorized as having either “reactive” management practices that address management problems as they occur or “proactive” management practices that pre-emptively mitigate challenges before they arise.

What did we learn?

The study found that women receiving care at hospitals with the most proactive unit culture management had a higher risk of cesarean delivery, postpartum hemorrhage, blood transfusion, and prolonged hospital length of stay.

Conclusion: These counterintuitive findings may indicate that managers at these hospitals are focused on achieving different goals, such as neonatal outcomes or financial performance, which are not always aligned with maternal wellbeing.

Partners: Robert Wood Johnson Foundation, MASS Design Group

Study results viewbook: The Impact  of Design on Clinical Care in Childbirth, March 2017

The Ariadne Labs research team and architects from MASS Design Group examined 12 childbirth facilities representing a broad cross-section of childbirth options to understand how the physical environment impacts clinical decision-making.

They looked at everything from the overall configuration of the room to where outlets are placed, quality and type of lighting, and how easy it is to get a patient out of a room for surgery.  At the unit level, they examined the configuration of workspaces, the distance between rooms, and whether rooms are located down long corridors or in neatly organized pods.

What did we find?

• Facilities that had a small number of beds and large number of births were more likely to have high C-section rates
• Rooms were frequently designed more to facilitate medical interventions (such as monitoring) rather than to help women who would need to push during vaginal delivery.
• The presence of birth balls and similar equipment sped up the natural birthing process, as did rooms that were designed with sufficient space to enable mothers to easily walk around during labor.
• Reducing the distance between patient rooms left more time for medical personnel to spend with patients, which led to lower C-section rates.
• Facilities that were better equipped to respond to surges and lulls in patient volumes — including the ability to admit patients who arrived at the hospital in early labor and traditionally might not be admitted — had lower C-section rates.

Conclusions: Labor floor design and architecture plays a role in the complex set of factors that influence clinical decision making. This study provides the foundation for developing an evidence-based set of recommendations for how labor and delivery floor space can be optimized to support natural childbirth.

Partners: Square Roots, Ovuline, the Harvard Medical School Department of Health Care Policy and Blue Cross Blue Shield of Massachusetts

Study results: Birth, How do pregnant women use quality measures when choosing their obstetric provider?, January 2017

Research clearly demonstrates that choice of hospital where a woman gives birth may be her biggest risk factor for having an unnecessary C-section. Yet, this study found that most women don’t factor hospital C-section rates into their decision-making about where to receive care.

Ariadne Labs collaborated with Ovuline to use the Ovia Pregnancy mobile app to survey 6,141 pregnant women from around the country. The results provide important new insights into how women incorporate hospital quality measures when choosing where to give birth.

What did we learn?

• Women chose their obstetrician or midwife first and give relatively little consideration to where they would give birth, expecting that their clinician would be doing the delivery
• While 75 percent of women recognize that quality of care is different across hospitals, only 17 percent chose their hospital first, compared to 73 percent who chose their obstetrician/midwife first.
• When asked how large a differential in cesarean delivery rate between two hospitals would need to be to influence their choice, 75 percent of women answered that no differential would be large enough to matter.
• Only 44 percent of women said they would be willing to travel 20 additional miles further from home to deliver at a hospital with a 20 percent lower cesarean delivery rate.
• Overall, women felt that a high C-section rate at a given hospital would not apply to them

Conclusions: More consumer education is needed so that mothers-to-be recognize how hospital-level C-section rates can affect their birthing experiences. Specifically, women should be aware that their obstetrician or midwife may not deliver their baby and that hospital C-section rates are the strongest indicator of whether they will have a C-section.

Partners: Stanford University School of Medicine

Study Results: Journal of the American Medical Association, Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality, December 2015

Rates of cesarean delivery vary widely from country to country, from as few as 2 percent to more than 50 percent of live births. The World Health Organization recommends countries not exceed 10 to 15 percent (10 to 15 C-section deliveries per 100 live births) for optimal maternal and neonatal outcomes. In this study, researchers examined the relationship between C-section rates and maternal and neonatal mortality in 194 countries.

What did we learn?

• As the country-level C- section rate increases up to 19 percent, maternal and neonatal mortality rates decline.
• C-section delivery rates above 19 percent showed no further improvement in maternal and neonatal mortality rates.

Conclusions: While there are many countries where not enough C-sections are being performed to protect the lives of women and infants, conversely, there are many countries where more C-sections are likely being performed than yield health benefits. The findings also suggest that policy benchmarks for country-wide C-section levels should be re-examined.

Partners: CRICO, Massachusetts Institute of Technology

The way beds, staff, and equipment are allocated within a hospital service can have a significant impact on care.  The Institute of Medicine describes this as a “scheduling” problem to ensure the right resources are delivered to the right patient at the right time. In childbirth, the rules for scheduling resources are undefined.  On a labor and delivery floor, the person in charge of these decisions is usually a senior nurse, “the resource nurse,” with years of frontline experience.

This ongoing study aims to define the rules that high-performing resource nurses use almost intuitively to make these decisions. Working with computer scientists from MIT, the team designed, developed and tested a software game that realistically simulates the clinical activity of the labor and delivery unit, and allows users to act as the resource nurse. The goal is to integrate these decision-making insights into a scalable intervention to improve care.

Partners: Aalborg University, Denmark

Study results: JAMA Surgery, Association of Previous Cesarean Delivery With Surgical Complications After a Hysterectomy Later in Life, August 2017

This study is the first to estimate population-wide long-term health risks from C-sections. Researchers examined a nationwide database of 7,685 women who gave birth over a 20-year period in Denmark. Researchers found that women who give birth by cesarean may face significant long-term health risks later in life, including an increased risk of needing a hysterectomy and more surgical complications when undergoing a hysterectomy.

What did we learn?

• Women who had at least one birth and a hysterectomy, were 50 percent more likely to have delivered their baby by C-section than the general population, suggesting that receiving a C-section may put women at a higher risk of needing a hysterectomy later in life.
• Compared to women who gave birth vaginally, women who had a C-section and later needed a hysterectomy were 16 percent more likely to experience postoperative complications such as bleeding or infection and 30 percent more likely to require reoperation.
• Those who had two or more C-sections were 96 percent more likely to require blood transfusions during the hysterectomy.

Conclusions: Study authors theorize that the increased risk of complications is caused by surgical adhesions that result from surgery. Because women often have more than one baby, surgeons routinely cut on the same scar – the same scar used for hysterectomies. The internal tissue starts to fuse together, making surgery more technically difficult. The findings point to the need for policies and clinical efforts to prevent medically unnecessary cesarean deliveries.