Most women don’t value hospital C-section rates in choosing where to give birth, according to new study



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Deborah O’Neil
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BOSTON, MA (Jan. 26, 2017) — Even though the hospital where a woman gives birth may be her biggest risk factor for having an unnecessary C-section, a new study by Ariadne Labs suggests most women don’t factor hospital quality into their decision making about where to receive care.

The study led by Dr. Neel Shah, director of the Delivery Decisions Initiative at Ariadne Labs and an obstetrician-gynecologist at Beth Israel Deaconess Medical Center, appears in the January 26 edition of the journal Birth. The study surveyed 6,141 pregnant women from around the country using the Ovia Pregnancy mobile app to understand how women incorporate hospital quality measures when choosing where to give birth.

The findings represent an important, and until now, under-studied patient perspective on the issue of what is driving skyrocketing C-section rates in the U.S. Hospital to hospital, C-section rates vary from 7 to 70 percent across the country. A C-section rate is understood by health-care providers to be an important indicator of quality of care – generally, the lower the rate for uncomplicated deliveries, the better the quality of obstetric care. However, the study finds women do not seek information about C-section rates for the hospital where they will deliver, prioritizing instead their choice of obstetrician. The study further finds that many women do not look at C-section rates or other quality metrics because they do not believe it has a bearing on the care they personally would receive.

“What this study tells us is that there is a big disconnect between the way we currently measure and report quality of care, and the factors that women and their partners most value,” said Shah. “Our industry needs to do a better job of communicating why hospital choice matters.”

A key insight to emerge from the research is that women largely expect that their obstetrician or midwife will deliver their baby, so the hospital doesn’t matter. That assumption, says Shah, is not always correct.

“For women with low-risk pregnancies who are planning a natural delivery, there are a lot of reasons why your doctor may not end up delivering your baby,” Shah said. “We know from our related work that the hospital environment has a significant impact on how care is delivered. A doctor in hospital that is effectively managing the labor floor may make a different set of choices if she is placed in a hospital where beds availability is tight and there’s not enough nurses.”

Other key findings of the study:

  • While 75 percent of women recognize that quality of care is different across hospitals only 17 percent choose their hospital first, compared to 73 percent who choose their obstetrician/midwife first
  • Most women said they don’t know much about or would give a low priority to key quality markers including cesarean section rate, unexpected injury rate, maternal trauma rate, obstetrical infection rate, neonatal trauma rate and episiotomy rate
  • Three-quarters of women indicated that they would prefer not to have a cesarean delivery if it was not medically indicated. Most respondents did not believe that the hospital they chose would affect their chances of getting a cesarean delivery
  • When asked how large of a differential in cesarean delivery rate between two hospitals would influence their choice, 75 percent of women answered that no differential would be large enough to matter
  • Only 44 percent of women reported that they would be willing to travel 20 additional miles further from their home to deliver at a hospital with a 20 percentage point lower cesarean delivery rate.

The findings point to a need for more consumer education about how hospital-level quality metrics can affect women’s birthing experiences, including the fact that their chosen obstetrician or midwife may not deliver their baby. Study co-author Rebecca Gourevitch, a health policy research assistant at Harvard Medical School, said the health-care industry has an opportunity to better communicate why hospital quality matters.

“Encouraging women to use hospital-level quality metrics in choosing their childbirth hospital will require new ways to frame and disseminate hospital-level obstetric quality data,” the authors conclude. “Closing this gap in patient knowledge is essential to having women value and use hospital-level quality data.”

Study coauthors include Ateev Mehrotra, MD, MPH of Beth Israel Deaconess Medical Center; Grace Galvin, MPH; Melinda Karp, MBA; and Avery Plough, BA.

The project represents collaboration between Ariadne Labs; Square Roots, a mission-driven company focused on pregnancy health and wellness; Ovia Health, creator of Ovia Pregnancy, part of Ovia Health’s family of mobile apps, which has helped millions of women and families conceive faster and have healthier pregnancies; as well as the Harvard Medical School Department of Health Care Policy and Blue Cross Blue Shield of Massachusetts.