By Sandy Hemphill

In April 2011, a community hospital in Northern California changed the way it handled maternity patients. After the hospital policy change, the number of cesarean-section (C-section) deliveries dropped.

According to the Centers for Disease Control and Prevention, almost one in three babies were delivered by C-section in 2013. Although the surgical procedure is considered safe and is sometimes an elective (chosen) surgery, complications can arise that rarely happen with vaginal births. In many cases, once a woman has a C-section delivery, her future children must be delivered this way also.

Women whose maternity expenses are covered under a private healthcare insurer are more likely to have C-section deliveries than women on publicly funded healthcare plans. The California hospital’s policy change gave privately insured women the same 24-hour access to obstetricians (OBs) and midwives as its publicly insured patients already had and the number of C-section deliveries in privately insured patients dropped significantly as a result.

Marin General Hospital, Before and After

Before April 2011, Marin General Hospital followed the conventional arrangement for privately insured maternity patients. These women were treated by OBs in private practice, meeting with their patients in their private offices until time of delivery. If the patient had questions or concerns during pregnancy, she was instructed to call the doctor at home or in his/her office during business hours. Once labor started and the woman hospitalized, the nursing staff monitored labor until the final stage. At this time, the physician was called in from elsewhere to attend only the birth.

Maternity patients on the state’s publicly funded health insurance programs were treated by OBs hired by the hospital who worked exclusively at the hospital and had midwives to assist them. These patients had 24-hour access to the hospital’s in-house maternity staff throughout their pregnancies.

In April 2011, the hospital made two major changes affecting private maternity patients:

• Midwives became available to private patients 24/7.
• 10 private-practice OBs assumed duties as laborists, providing “in-house labor and delivery coverage without competing clinical (private practice) duties.”

Dr. Melissa Rosenstein thought this policy change presented the ideal opportunity to study the impact 24-hour access has on C-section delivery rates. Rosenstein is a member of the Obstetrics, Gynecology, and Reproductive Sciences department at the University of California San Francisco.

C-Section Rates Before and After

Rosenstein’s study involved review of medical records before and after the change for:

• 3,560 women giving birth for the first time, carrying one fetus situated in the normal, head-first position.
•  1,324 carrying single head-first babies had already given birth via C-section.
• Roughly half the women before and after the policy change were privately insured.

No significant changes occurred in the publicly insured cases before or after the change; it did not alter their care pattern. The C-section rates did drop after the policy change for privately insured patients:

• 31.7% had C-sections before the policy change.
• 25% had C-sections in the first year after it.

The C-section rate in privately insured patients continued to drop by almost 2% each year until the study ended in 2014.

The rate of vaginal deliveries rose for the privately insured patients who had C-section histories:

• 13.3% vaginal deliveries before the change.
• 22.4% after.

Why Fewer C-Sections

The research team can only speculate on why there were fewer C-sections after the change but some factors thought to influence the outcome include:

• The in-house laborists were not juggling private patient schedules and delivery duties.
• They were not distracted by office management responsibilities.
• The laborists might have been more willing to allow time for a vaginal delivery to occur naturally since they were at the hospital during a full shift, not just for a single delivery.
• The decision to perform a C-section was no longer made on the spot by an individual doctor.
• The in-house team of laborists and midwives discussed each patient twice a day and collectively explored alternatives whenever natural labor and delivery was questioned.

Sources:

1. Leigh, Suzanne. "24-Hour OBs, Midwives Lead to Less C-Sections." UCSF. The Regents of the University of California, 8 Sept. 2015. Web. 19 Sept. 2015.
2. "Pregnancy: Labor and birth." WomensHealth.gov. US Department of Health and Human Services, 27 Sept. 2010. Web. 19 Sept. 2015.