Nikkipowerpoint For Epi

: Transforming Maternity Care

Geographical Variations among Age-Adjusted Low-Risk Primary

Cesarean Section (CS) Rates in California

Nikki StoddartMasters Candidate

Division of Epidemiology

Department of Health Research and Policy

Stanford University, School of Medicine


A Brief History of Cesarean Birth

The Birth of Asclepius

1549 Alessandro Beneditti“De Re Medica”


Origins of Cesarean Birth

Historical record indicates infants born via Cesarean Greek Mythology: Apollo removed Asclepius

from Coronis’ abdomen Procedure performed on living women in

Ancient China


Suetonius 1506 WoodcutLives of the Twelve Caesares


Why is it Called “Caesarean”?

Named for the birth of Julius Caesar?Unlikely because in ancient Rome the

procedure was done only when the mother was dead or dying but Caesar’s mother, Aurelia, lived to hear of his Conquest of Britain.


Oh, I see….

Possibly from the Latin “caedare”, meaning “to cut”Roman Law stated that women dying in

childbirth must be cut open to remove the infant.

Latin word “caesones” refers to children born by postmortem incision.


Finally, we have a live one!

In 1500 Jacob Nufer, a Swiss pig gelder, performed a Cesarean on his ailing wife. She lived to be 77 years old, and birthed 5 more children vaginally, including a set of twins.


But Still Gruesome….

Between 1787- 1876, not a single Parisian woman survived the Cesarean operation.


Performing Abdominal Surgery in Street ClothesThomas Spencer Wells, Diseases of the Ovaries, 1872


From Fatal to….....Less Fatal

Maternal mortality rates dropped in the mid nineteenth century 1846 William Morton- Diethyl Ether

Women less likely to die from shock 1860’s Josef Lister- Carbolic Acid

Antiseptics and the germ theory


From Less Fatal…… To Safe

C/S rates increase because:Post WWII, many new hospitals built Surgical technique improvedSpinal Anesthesia developedPenicillin purified 1940Roman Catholic religious concerns


From Safe……to Every Day Continued rate increase far outpaces rise in birth rate

Convenience Physicians can schedule around vacations, dinnertime Women can schedule time off from work Cutting loses (Better a section a 6pm than a delivery at 3 am)

Culture “Too Posh to Push” – Victoria Beckam Vaginal Preservation Society

C.Y.A. Malpractice suits

twins , breech, or VBACs are too risky


Technology in the Labor Suite Strongly Correlates with CS rates Labor induction

r= 0.57 (P<.0001) Fetal monitoring Early Labor Admission

“Failure to progress” leads to CS r= .62 (P <.0001)


FinancialOb/gyn’s must do more deliveries to pay MIC/S birth reimbursement is higher than

vaginal


So, where does that leave us Today?

WHO and USDHHS recommend no more than 15% of all births be C/SBeyond 15%, risks begin to eclipse benefits

Yet 1/3 women in CA deliver via C/S


For every 5% decrease in the national primary CS rate there will be:

Between 14-32 fewer maternal deaths 33,000 fewer NICU admissions An savings of $750 million -$1.7 billion in

healthcare costs.Plante 2006


Risks of CS to Mother

Blood Loss/Transfusion ≥ 1000 ml Postoperative Infections Subsequent Infertility Subsequent increased risk: placenta previa, placenta accreta, placental

abruption and hemorrhage Injury to bowel, bladder, pelvic vasculature Rehospitalization Maternal Mortality

RR: 1.6- 2.8


Risks of CS to Fetus

Higher rates of respiratory distress5% C/S 0.5% vaginal

Possible iatrogenic prematurity Double risk of NICU admission Double risk of unexplained stillbirth in

subsequent pregnancy


CONTENTS FRAGILE

DO NOT USE KNIFE TO OPEN


Objectives

Identify regional variations of Age Adjusted Low-Risk C/S rates in California Simplify regions: Northern, Southern CA and LA

County Identify excess rates of C/S deliveries

(Exclude Hospitals with less than 100 births per year) Inform hospital leaders; lead quality change


Low-Risk Primary Cesarean Section Defined:

Number of Cesarean Deliveries per 100 deliveries among women who have not previously had a Cesarean section (excludes abnormal presentation, preterm, fetal death, multiple gestation, and breech procedures)Primary C/S rates are age-adjusted.

OSHPD Data 2006


Age-Adjusted Low-Risk Primary C/S Rates distributed to quintiles and

applied to regions:

0-20%; (Quintile 1: 5-13) 20-40%; (Quintile 2: 14-15) 40-60%; (Quintile 3: 16.1-16.9) 60-80%; (Quintile 4: 17-19) 80-100%;(Quintile 5: 19+)

Quintile ranges are per 100 births


Top and Bottom two Quintiles (40%) of Age-adjustedLow-Risk Primary C/S Rates: Northern CA

Hospitals with rates > 17

n = 32/124 (25%)

Hospitals with rates < 16

n=74/124 (60%)


Top and Bottom two Quintiles (40%) of Age-AdjustedLow-Risk Primary C/S Rates: LA County CA

Hospitals with rates >17n=44/60 (73%)

Hospitals with rates < 16n=12/60 (20%)


Top and Bottom two Quintiles(40%) of Age-AdjustedLow Risk Primary C/S Rates: Southern CA

Hoag memorial

Scripps La Jolla

Hospitals with rates >17n=34/80 (43%)

Hospitals with rates < 16 n=40/80 (50%)


Public Health Implications of Cesarean on DemandLauren Plante 2006


What are the total regional excess cases above California’s mean primary

C/S rate (16 per 100 live births)?


Excess Cases of Low-risk Primary Cesarean Births (age-adjusted)

above the State mean of 16 per 100 births.By Hospital

San Francisco Bay Area 2006

Total Excess C/S Cases= 349 (3%)Total low-risk non prior C/S= 11,043 (11%)

Total Live Births= 97,000

Good Samaritan San Jose

Hospitals with more than 200 Excess Cases are labeled


Valley Pres

Cedars Sinai Hollywood PresCitrus MemorialGarfield

Huntington Park


above the State mean of 16 per 100 births.

By Hospital, LA County 2006

Total Excess C/S Cases= 4368 (20%)Total low-risk non-prior C/S= 22,327 (20%)




above the State mean of 16 per 100 births.

By Hospital, Northern CA 2006

Total Excess C/S Cases= 1312 (5%) Total Non-Prior C/S= 23,745 (11%)


Good Samaritan San Jose

Hospitals with more than 200 Excess Cases are labeled


Birth Costs (In thousands)

Physician Cost Hospital Cost Total Cost0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

Vaginal BirthCesarean Birth


Financial Implications of California’s Excess Cases (Complications excluded)

Total excess cases above state mean: 17,677

Excess Healthcare Costs per Annum: $ 93,422,945.00

Total excess cases above 15 (WHO Recommendation): 40,654

Excess Healthcare Costs per Annum: $214,856,390.00


Conclusion:

Next Steps?

Questions/Comments?What benchmark should we use? Is Geomapping a useful tool for sharing data?

Health & Medicine

Nikkipowerpoint For Epi