dr. adam wolfberg is an obstetrician, a runner, and a writer.

Build culture; improve outcomes

This post appeared on the OviaHealth blog on January 18, 2019.

In the 15 years I have practiced obstetrics, I have been the surgical assistant on hundreds of cesarean deliveries that seemed to me, at the time, to be unnecessary, and I’ve been the surgeon of record for a handful of unnecessary cesarean deliveries myself. I know firsthand how difficult it is for physicians, nurses, policy makers, and administrators, all of whom are well aware that the United States has a cesarean epidemic, to wrestle with it.

There are some decisions a woman can make to reduce her chance of ending up in an operating room: select a healthcare provider who delivers at a hospital with a low cesarean rate; choose a midwife (if clinically appropriate); stay home until genuinely in labor; and bring a support person when she labors. Physicians and hospitals also can work to safely reduce their own cesarean rates, however few interventions have been successful. That’s why it’s worth highlighting an initiative that is working and has made a huge impact on the cesarean rate at one hospital.

Dr. Aaron Caughey’s team at Oregon Health Sciences University (OHSU) started a one-hour, weekly review of every cesarean delivery performed in the prior week, and invited pretty much everyone to attend: midwives, obstetricians, family practice physicians, nurses, residents, high-risk specialists, and anesthesiologists. At the non-mandatory meeting, they reviewed each patient’s care. Had she been in labor and if so, for how long and what happened during her labor? What was the decision-making process that led to the surgical intervention? What was the clinical indication for the surgery and was it justified by generally-accepted standards of practice? What was the outcome for the mother and her baby?

Then, like all wonderfully curious scientists, Caughey’s team, led by medical student Ashley Skeith, compared the cesarean rate in the 13 months prior to their first weekly meeting to a 28-month period of time beginning six months after the weekly meetings became a habit. The results were fairly dramatic. Across all categories of patients (thin, obese, first-time mothers, women with prior children, scheduled and unscheduled deliveries) the cesarean rate at OHSU declined 25-30 percent. Their research was recently published in Obstetrics & Gynecology.

I asked Caughey why it worked, and non-intuitively, he focused on culture change. Culture gets short shrift in medicine, but it’s probably the most important factor in making great organizations successful. Caughey recognized that disparate members of the labor team were inherently in favor of eliminating unnecessary surgeries. Nurses, midwifes, and family practice physicians were strong proponents; the obstetricians and the high-risk specialists weren’t opposed, but cesarean reduction wasn’t a priority for them.

“When I got to OHSU, the culture was divisive and many of the physicians did not particularly value achieving vaginal birth,” Caughey wrote in an email. “I had come from the University of California San Francisco (UCSF) where we were really one provider group and practice management was commonly discussed at rounds. I did not find this at OHSU where there were four separate practices - midwifery, family medicine, OB/GYN, and maternal-fetal medicine (high-risk specialists), and practice management was not discussed much between the groups.  This meeting brought folks from different practices together to discuss labor management which I don’t think had happened as much.”

Think about it: a focus on healing a divisive culture and creating a forum for communication about a clinical problem led to a 25 percent reduction in the cesarean rate within just a few months. It makes me wonder whether a focus on leadership and culture could impact the cesarean epidemic in a way that other interventions cannot.

Could you be the leader at your hospital to create this kind of culture change and positively impact this many lives?

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