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C-section rates improve dramatically at Cleveland Clinic

STORY BY MICHELLE GENZ (Week of March 11, 2021)

The improvement couldn’t have come at a more welcome time. As Cleveland Clinic Indian River Hospital was doing all it could to prevent unnecessary hospital stays during COVID-19, a dedicated team in maternal health managed to reduce by a third the number of C-sections in first-time, low-risk deliveries.

The 10-point reduction – from 31 percent in 2019 to 21 percent in 2020 – earned the hospital recognition at a statewide conference. The good news was reported by Megan McFall, director of women’s health at the hospital, at last month’s Indian River County Hospital District board meeting.

The rate bested the target of 23.9 percent set by the Healthy People 2020 national initiative. So far, only a fifth of Florida’s hospitals have achieved that goal.

The goal was surpassed here through a year-long collaborative effort led by McFall and a team she assembled that included obstetricians from both private practice as well as the hospital’s Partners in Women’s Health clinic, which gets support for prenatal care from the hospital district. The team had the guidance of the Florida Perinatal Quality Collaborative, part of the University of South Florida’s College of Public Health.

Indian River has been working with that group since 2012, when the hospital took part in a successful effort to reduce maternal hemorrhage.

This latest achievement in reducing cesareans was significant enough to be hailed by the Collaborative’s director, Dr. Bill Sappenfield, who invited the effort’s leadership team to the Florida Hospital Association’s annual meeting.

“Our unit was recognized for utilizing best practices to drive outcomes,” McFall reported proudly to the hospital district board. She was asked to present the data to the hospital district board by Trustee Allen Jones, who has singled out maternal, fetal and infant health as a key focus of the district.

Cleveland Clinic Indian River’s work with the Collaborative on C-sections began in November 2019. That was months before the pandemic arrived in Vero, and the hospital was concerned with the spread of a more mundane menace – bad publicity.

Word had come earlier that year that starting in July 2020, the Joint Commission, the national hospital accreditation group, would begin publicly reporting C-section rates for hospitals with chronically high rates – those greater than 30 percent.

That move to out hospitals with high C-section rates came after studies showed no improvement in C-section rates in recent years. There was also new evidence that C-sections could be reduced without an increase in medical complications in the newborn.

The Joint Commission chose to assess the rates of what are known as NTSV cesareans – surgical deliveries performed on women having their first baby when the baby is head-down in the uterus, the least complicated position for a successful birth.

Other more complex pregnancies may also be able to avoid C-sections. Babies in the wrong position can sometimes be turned, for example. And there are an increasing number of vaginal deliveries that follow a previous C-section.

Such births can usually be safely managed but are often banned because of low but serious risks to mother and child. At Cleveland Clinic, such births after a prior cesarean are allowed in some but not all cases.

The Joint Commission has stressed that reducing C-sections in first-time mothers – considered a low-risk population – was the best start toward reducing C-sections overall.

“The leadership team at Cleveland Clinic Indian River cannot ignore that our primary C-section rate was above the Florida and national average coming in at 31 percent,” McFall said.

“We knew these unfavorable rates would be published nationally by the Joint Commission.”

C-sections also mean higher medical costs, estimated at $5,000 to $10,000 more than vaginal deliveries. In hospital costs alone, the state reports a savings of $4,000 for each Medicaid and privately insured patient who delivers vaginally instead of by C-section, McFall said.

Along with adding to the state’s Medicaid burden as well as private insurer expenses, those additional costs have to be absorbed by Cleveland Clinic if the mother qualifies for the hospital’s charity care.

After a January kickoff, Cleveland Clinic paid for its bedside obstetrics nurses to go to a statewide seminar staged by the perinatal initiative to learn how to support mothers through labor.

Along with reviewing the data concerning C-sections’ morbidity and mortality, the nurses learned the latest recommendations and clinical ramifications of labor on skills ranging from checking fetal heartbeats to palpating the uterus and getting hands-on practice with helping mothers position themselves through the arduous process.

McFall also included members of the county’s Healthy Start initiative. That group, which also gets financial support from the hospital district, trains and schedules doulas – at no cost to the mother – to be present during deliveries and offer guidance through childbirth. “Doulas decrease C-section rates tremendously,” McFall said.

The perinatal initiative also urged the Indian River team to create checklists for doctors to document how decisions were reached for artificially inducing labor with medication, an intervention that can also lead to C-section.

“Physicians and patients alike will often request to schedule an induction,” said McFall. To help guide the decision process, McFall’s team developed an “induction booking sheet” to be used at every induction.

“This form ensures that we are being thoughtful about the process of inducing patients, ensuring we are following strong clinical practice recommendations and that we are not inducing a mother too early, which will contribute to an increase in C-section rates,” McFall said.

There is no word yet on whether overall C-sections – not just for first-time mothers – also are down at the Vero hospital, though the Joint Commission said that is a logical expectation.