The most recent cesarean rate in the United States stands at 32.0%. Almost one in three people (more than 1,300,000) who give birth in the USA do so via major abdominal surgery. In one generation, the United States has seen a 500% increase in the number of cesarean births. The consequence of so many cesarean births has been an increase in maternal mortality and morbidity both during that birth in the form of hemorrhage or infection, longer hospitalizations, and greater average costs than vaginal deliveries. There are also significant downstream consequences for future pregnancies, labors, and births. Research indicates that 45% of all cesareans done in the United States are most likely avoidable. Hospitals in the USA display a ten-fold variation in cesarean rates, (7-70%) and the reasons for this is complex. It is not a simple situation of those hospitals with high-risk patients are doing more cesareans. The variation can not be easily explained and it is present even after adjusting for the health of the mothers, preferences, and sociodemographics. This leads researchers to believe that there is significant opportunity to improve the safety, quality of care and care experience that is available to maternity consumers today.

A new paper published online today in Obstetrics & Gynecology, "Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes," becomes the first study of its kind to link management of unit culture, nursing, and patient flow to maternal health outcomes. The research team spent over three years analyzing data from over 220,000 deliveries at 53 hospitals. Site visits were made to a subset of these hospitals. It was 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.

Lead author Avery Plough, an Ariadne Labs researcher, 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 or "proactive" management practices. Reactive management practices address management problems as they occur. Proactive management practices pre-emptively mitigate challenges before they arise.

It is no easy task to run a labor and delivery unit. There are so many independent factors and situations that can change at any moment. Anything can happen and often does. How does a facility plan for everything from the uncomplicated, spontaneous labors and births to precarious unknown complications or just simply a rush of laboring people arriving all at the same time? I can understand how being "proactive" can potentially make the management of this complex, unpredictable, constantly moving system just a bit more do-able.

This study looked at how those management practices affected the health of low-risk women having their first child. The results showed that patients 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. These are all measures of maternal morbidity. These counterintuitive findings may indicate that managers at these hospitals are focused on achieving different goals, such as improved neonatal outcomes or financial performance, which are not always aligned with maternal wellbeing.

In facilities that routinely handle complex obstetrical cases and situations, management may be optimized to care for the highest risk patients rather than lower risk patients. This may highlight the importance of future work to develop and scale management best practices for smaller, community-based or critical access hospitals.

Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

The upshot is that after accounting for every fixed, observable characteristic of a mother who enters the hospital, and every fixed, observable characteristic of the hospital, the last and final thing that appears to predict the mother's chance of a c-section or hemorrhage is how the labor and delivery unit is managed.

There are many more questions that are raised after one examines the results of this study. It is clear that additional research on this topic is called for. But according to Neel Shah, MD, MMP ' "one can state that this groundbreaking study implies that management goals matter as much as management practices. 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."

The research is an important cornerstone of Shah's Delivery Decisions Initiative at Ariadne Labs to identify the key drivers of dangerously high cesarean section rates and to develop a health system-level solution to the problem. I look forward to further studies that can identify changes that will improve maternal and neonatal mortality and morbidity.

Resources

Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes,' Avery C. Plough, Grace Galvin, Zhonghe Li, Stuart R. Lipsitz, Shehnaz Alidina, Natalie J. Henrich, Lisa R. Hirschhorn, William R. Berry, Atul A. Gawande, Doris Peter, Rory McDonald, Donna L. Caldwell, Janet H. Muri, Debra Bingham, Aaron B. Caughey, Eugene R. Declercq, Neel T. Shah, Obstetrics and Gynecology, July 11, doi: 10.1097/AOG.0000000000002128

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