Dr. Neel Shah, MD, MPP, will be the featured speaker at the Quality Institute’s Spring All Council Conference. Dr. Shah is an Assistant Professor at Harvard Medical School and Director of the Delivery Decisions Initiative at the Ariadne Labs for Health Systems Innovation. He is an expert in designing, testing and spreading system interventions that improve safety, affordability and experience of patient care.
We’ve seen an enormous rise in the rate of Cesarean sections — from about 5 percent of all births in the 1960s and early 1970s to as many as one third of all births today. You are dedicated to understanding this enormous and complex change in childbirth. What have you learned?
There’s a lot of conventional wisdom of why we have seen a 500 percent increase in this major surgery in a generation or two of mothers. But that conventional wisdom does not bear out. Part of what I have learned is what’s not driving the increase. People say women are demanding C-sections. That’s not true. Less than half of one percent of women request C-sections. Some people think the driver is medical malpractice. That’s a potential cause for some C-sections, but during eras when medical malpractice policies have not changed we’ve still seen this enormous increase in C-sections. Others say it’s reimbursement. During periods where reimbursement policies have not changed we’ve still seen this increase. Others say that moms are different today than moms in 70s. They are older. There’s more obesity, IVF, twins. There’s more hypertension and diabetes. That’s not a satisfactory explanation. C-sections have gone up just as much in 18-year-olds as they have in 35-year-olds.
So what do you think is the driver of the enormous increase in this major surgery?
A lot of people think they know what’s going on, but the truth is we don’t have any satisfactory explanations. My personal theory, and this is complex and is what I will discuss at my talk at the Quality Institute, is that in every other domain increased scientific capability has made our lives simpler. Anyone who has sent an email today knows that communication is simpler. Getting around is simpler. But in health care science has vastly increased our capabilities but also made our lives much more complicated — both as clinicians and as patients. And as payers and insurers. I believe the increase in C-sections in this country is actually a consequence of the complexity of the system we have created. The variation of rates from place to place is a consequence of our varying ability to manage that complexity.
Have we seen improvements in neonatal outcomes to justify the increase in C-sections?
We have seen improvements in neonatal outcomes in past decades. But it’s a complicated story there. The improvements have been in premature babies and high-risk babies. We have not seen improvements in low-risk births where the baby is full term, there is only one baby, and the baby is pointing in the right direction to come out. Yet we see a lot of variation in care for these low-risk women. For low-risk women, the increase in C-sections has not made their babies better off.
What are your observations about what’s happening in New Jersey?
New Jersey has tremendous variation in C-section rates from place to place. New Jersey is unique and has the nation’s densest population. It’s very different from places where a woman may have to drive hours to get prenatal care. In New Jersey, there is a hospital everywhere you look and intense competition for customers in the health care delivery system. And when you have such great variation in quality and competition for services — and a super-discerning population — pregnant women give up sushi and alcohol; they are super committed — it is just a matter of time before hospitals are held accountable for their C-section rates. … The information economy is the single most disruptive force in the world right now. For instance, we are studying a fertility-tracking app that hundreds of thousands of pregnant women use. We are enrolling 20,000 women and giving them targeted information about C-section rates to see if that will influence where they go to give birth.
How does your work in maternity care relate to the larger picture of what’s happening in health care today.
The biggest challenge we face today — the Holy Grail — is figuring out how we can deliver better care at lower cost. We used to think that saving money and improving care were goals moving in opposite directions. Now we see that people get hurt when we do too little but also when we do too much. Now there are so many examples of how we can do less, save money, and make patients healthier — all at the same time. It turns out that maternal health is the prototypical example. If we can find a way to intentionally decrease C-section rates across the entire United States — if we can find a solution that can work in New Jersey and in New Mexico —it will be a great example of what we could be doing in the rest of health care to reduce unnecessary interventions, unnecessary hospitalizations and other things that really hurt people. And maternity is a big piece of the pie. Twenty five percent of all hospitalizations are related to childbirth. In 2017, when health care moves toward population health and management of entire communities, the labor floor is your front door. Every stakeholder is beginning to pay more attention to how we treat our moms.