Cesarean Delivery and Hospitals: Size Matters

In this issue of JFP, Janssen and colleagues¹ document that low-risk women delivering at a tertiary-care maternity hospital had 3.4 times the likelihood of cesarean delivery of similar low-risk women delivering at a nearby community hospital (95% confidence interval, 2.1-5.4). Differing rates of epidural analgesia appeared to be the most significant association with cesarean delivery.

This study adds to the data suggesting that epidurals increase the cesarean delivery rate, but the controversy about the cause-and-effect role of epidurals in cesarean delivery is extensive, complicated, sometimes heated, and destined to continue. The consideration of factors that might account for the differing cesarean delivery rates arouses 2 more interesting and complex questions. First, how do my attitudes and behaviors as a physician interact with those prevalent in my practice setting to determine the fate of my patient? Second, can patients use information about differing institutional and physician cesarean rates to make choices about whom they select for a maternity care provider and where delivery takes place?

Factors affecting maternity care

Physician specialty, institutional practices, and geographic location are known to affect the use of tests, therapies, procedures, and patient outcomes in a wide range of conditions, including maternity care. Even within a specialty such as obstetrics, different institutions, different geographic areas, and individual care givers within a given institution produce widely differing rates of cesarean delivery for similar patients.^2-4 Some physicians may consciously or unconsciously consider every patient to be on the verge of disaster and in need of interventions until proven otherwise: “There is no low-risk obstetrics patient, only high-risk and unknown risk.” Others view pregnancy and birth as natural processes that will most often proceed normally if left alone except for support and encouragement. Although it is a generalization that does not hold true for all individuals, obstetricians are generally found to practice a more interventional style, while family physicians and midwives increasingly tend to be less interventional.^5-7

Maternity care practices and outcomes are also subject to strong influence by the institutional environment and culture. This may be particularly important in understanding the differences in cesarean delivery rates between some tertiary-care centers and community hospitals as demonstrated in the study by Janssen and colleagues. It is the nature and mission of a tertiary-care center to attract patients with complications. These centers house systems to care for complicated cases and keep those systems and necessary personnel at the ready. Trainees eager to intervene may also be present. This may create an environment in which interventions designed for patients with complications spill over to patients without complications.

This tertiary-care institution effect can be powerful. In these environments the care provided by family physicians and the resulting outcomes, including cesarean delivery rates, tend to resemble those of the dominant culture.⁸ In the study by Janssen and coworkers, family physicians were more numerous than obstetricians in both hospitals (3:1 at the tertiary-care center and 12:1 in the community hospital). Although we can assume that family physicians delivered the majority of babies in the community hospital, the data in the study do not reveal what percentage of babies were delivered by family physicians in the tertiary-care center. Although more prevalent numerically, the family physicians may not have been (and probably were not) the dominant culture in the tertiary-care center.

Another recognized component of the institutional effect is nursing care style, with the likelihood of whether any given patient is delivered vaginally or by cesarean being directly related to the individual nurse caring for her. Some features of nursing care that may relate to patient outcome include the following: time spent with the patient, technique of fetal monitoring, nursing expectations, and the type and timing of analgesia offered.⁹

Patient demographics and expectations were examined in the study by Janssen and colleagues, and no differences were found. However, we do not know if patient expectations may have affected her choice of a care provider or her choice of a place of delivery. It makes sense that patients motivated to have less intervention and not wanting epidural analgesia would seek out the community hospital if the hospital’s usual practices were known to them.

Other questions to consider

Thus as Janssen and coworkers suggest, epidural analgesia may represent a proxy for a large conglomeration of other small parameters that do not themselves reach statistical significance. Most of these small parameters appear to be under human control, and it is in regard to them that we need to examine our attitudes and actions on behalf of our patients. Instead of examining our cesarean rates or our epidural rates, it may be more important to ask ourselves 2 questions: First, do we view labor and birth as natural processes? Second, do we base interventions on evidence that they will do more good than harm? We may never have the answer to “What is the right number of cesarean deliveries?”¹⁰ However, we are more likely to approach the right number by making sure we can answer the first 2 questions affirmatively than by agonizing over the statistics related to various parts of the patient’s care.

What about the babies? There was no statistically significant difference in the current study between APGAR scores at the 2 hospitals, indicating that the increased cesarean delivery rate at the tertiary-care center did not produce improved short-term infant outcomes for the low-risk patients as assessed by this one parameter. This is an often-repeated story. Other studies that have examined other parameters have shown that term, normal birthweight infants can have better outcomes at community hospitals than at tertiary-care centers, possibly related to the effect of the previously mentioned physician and institutional factors on their mother’s intrapartum care.^11-13

Conclusions

Janssen and colleagues make us think about our role as family physicians who provide maternity care and about what our patients should know. Although family physicians do have important maternity care roles in tertiary care centers as care providers, teachers, and role models, most of us provide care in community hospital settings. Although family physicians deliver approximately 20% of the babies in the United States, we deliver a much larger portion in smaller communities and are the main maternity care providers in rural areas. Providing this access is very important, since we know that pregnancy outcomes are poorer when maternity care is not available locally and women must travel for that care.^14,15 Modern medicine has fostered a “bigger is better” mentality, but this study and others like it provide evidence that where hospitals are concerned size matters in an unexpected way: Low-risk women and their babies may be better off in community hospitals than in tertiary-care centers.

In this issue of JFP, Janssen and colleagues¹ document that low-risk women delivering at a tertiary-care maternity hospital had 3.4 times the likelihood of cesarean delivery of similar low-risk women delivering at a nearby community hospital (95% confidence interval, 2.1-5.4). Differing rates of epidural analgesia appeared to be the most significant association with cesarean delivery.

This study adds to the data suggesting that epidurals increase the cesarean delivery rate, but the controversy about the cause-and-effect role of epidurals in cesarean delivery is extensive, complicated, sometimes heated, and destined to continue. The consideration of factors that might account for the differing cesarean delivery rates arouses 2 more interesting and complex questions. First, how do my attitudes and behaviors as a physician interact with those prevalent in my practice setting to determine the fate of my patient? Second, can patients use information about differing institutional and physician cesarean rates to make choices about whom they select for a maternity care provider and where delivery takes place?

Factors affecting maternity care

Physician specialty, institutional practices, and geographic location are known to affect the use of tests, therapies, procedures, and patient outcomes in a wide range of conditions, including maternity care. Even within a specialty such as obstetrics, different institutions, different geographic areas, and individual care givers within a given institution produce widely differing rates of cesarean delivery for similar patients.^2-4 Some physicians may consciously or unconsciously consider every patient to be on the verge of disaster and in need of interventions until proven otherwise: “There is no low-risk obstetrics patient, only high-risk and unknown risk.” Others view pregnancy and birth as natural processes that will most often proceed normally if left alone except for support and encouragement. Although it is a generalization that does not hold true for all individuals, obstetricians are generally found to practice a more interventional style, while family physicians and midwives increasingly tend to be less interventional.^5-7

Maternity care practices and outcomes are also subject to strong influence by the institutional environment and culture. This may be particularly important in understanding the differences in cesarean delivery rates between some tertiary-care centers and community hospitals as demonstrated in the study by Janssen and colleagues. It is the nature and mission of a tertiary-care center to attract patients with complications. These centers house systems to care for complicated cases and keep those systems and necessary personnel at the ready. Trainees eager to intervene may also be present. This may create an environment in which interventions designed for patients with complications spill over to patients without complications.

This tertiary-care institution effect can be powerful. In these environments the care provided by family physicians and the resulting outcomes, including cesarean delivery rates, tend to resemble those of the dominant culture.⁸ In the study by Janssen and coworkers, family physicians were more numerous than obstetricians in both hospitals (3:1 at the tertiary-care center and 12:1 in the community hospital). Although we can assume that family physicians delivered the majority of babies in the community hospital, the data in the study do not reveal what percentage of babies were delivered by family physicians in the tertiary-care center. Although more prevalent numerically, the family physicians may not have been (and probably were not) the dominant culture in the tertiary-care center.

Another recognized component of the institutional effect is nursing care style, with the likelihood of whether any given patient is delivered vaginally or by cesarean being directly related to the individual nurse caring for her. Some features of nursing care that may relate to patient outcome include the following: time spent with the patient, technique of fetal monitoring, nursing expectations, and the type and timing of analgesia offered.⁹

Patient demographics and expectations were examined in the study by Janssen and colleagues, and no differences were found. However, we do not know if patient expectations may have affected her choice of a care provider or her choice of a place of delivery. It makes sense that patients motivated to have less intervention and not wanting epidural analgesia would seek out the community hospital if the hospital’s usual practices were known to them.

Other questions to consider

Thus as Janssen and coworkers suggest, epidural analgesia may represent a proxy for a large conglomeration of other small parameters that do not themselves reach statistical significance. Most of these small parameters appear to be under human control, and it is in regard to them that we need to examine our attitudes and actions on behalf of our patients. Instead of examining our cesarean rates or our epidural rates, it may be more important to ask ourselves 2 questions: First, do we view labor and birth as natural processes? Second, do we base interventions on evidence that they will do more good than harm? We may never have the answer to “What is the right number of cesarean deliveries?”¹⁰ However, we are more likely to approach the right number by making sure we can answer the first 2 questions affirmatively than by agonizing over the statistics related to various parts of the patient’s care.

What about the babies? There was no statistically significant difference in the current study between APGAR scores at the 2 hospitals, indicating that the increased cesarean delivery rate at the tertiary-care center did not produce improved short-term infant outcomes for the low-risk patients as assessed by this one parameter. This is an often-repeated story. Other studies that have examined other parameters have shown that term, normal birthweight infants can have better outcomes at community hospitals than at tertiary-care centers, possibly related to the effect of the previously mentioned physician and institutional factors on their mother’s intrapartum care.^11-13

Conclusions

Janssen and colleagues make us think about our role as family physicians who provide maternity care and about what our patients should know. Although family physicians do have important maternity care roles in tertiary care centers as care providers, teachers, and role models, most of us provide care in community hospital settings. Although family physicians deliver approximately 20% of the babies in the United States, we deliver a much larger portion in smaller communities and are the main maternity care providers in rural areas. Providing this access is very important, since we know that pregnancy outcomes are poorer when maternity care is not available locally and women must travel for that care.^14,15 Modern medicine has fostered a “bigger is better” mentality, but this study and others like it provide evidence that where hospitals are concerned size matters in an unexpected way: Low-risk women and their babies may be better off in community hospitals than in tertiary-care centers.

In this issue of JFP, Janssen and colleagues¹ document that low-risk women delivering at a tertiary-care maternity hospital had 3.4 times the likelihood of cesarean delivery of similar low-risk women delivering at a nearby community hospital (95% confidence interval, 2.1-5.4). Differing rates of epidural analgesia appeared to be the most significant association with cesarean delivery.

This study adds to the data suggesting that epidurals increase the cesarean delivery rate, but the controversy about the cause-and-effect role of epidurals in cesarean delivery is extensive, complicated, sometimes heated, and destined to continue. The consideration of factors that might account for the differing cesarean delivery rates arouses 2 more interesting and complex questions. First, how do my attitudes and behaviors as a physician interact with those prevalent in my practice setting to determine the fate of my patient? Second, can patients use information about differing institutional and physician cesarean rates to make choices about whom they select for a maternity care provider and where delivery takes place?

Factors affecting maternity care

Physician specialty, institutional practices, and geographic location are known to affect the use of tests, therapies, procedures, and patient outcomes in a wide range of conditions, including maternity care. Even within a specialty such as obstetrics, different institutions, different geographic areas, and individual care givers within a given institution produce widely differing rates of cesarean delivery for similar patients.^2-4 Some physicians may consciously or unconsciously consider every patient to be on the verge of disaster and in need of interventions until proven otherwise: “There is no low-risk obstetrics patient, only high-risk and unknown risk.” Others view pregnancy and birth as natural processes that will most often proceed normally if left alone except for support and encouragement. Although it is a generalization that does not hold true for all individuals, obstetricians are generally found to practice a more interventional style, while family physicians and midwives increasingly tend to be less interventional.^5-7

Maternity care practices and outcomes are also subject to strong influence by the institutional environment and culture. This may be particularly important in understanding the differences in cesarean delivery rates between some tertiary-care centers and community hospitals as demonstrated in the study by Janssen and colleagues. It is the nature and mission of a tertiary-care center to attract patients with complications. These centers house systems to care for complicated cases and keep those systems and necessary personnel at the ready. Trainees eager to intervene may also be present. This may create an environment in which interventions designed for patients with complications spill over to patients without complications.

This tertiary-care institution effect can be powerful. In these environments the care provided by family physicians and the resulting outcomes, including cesarean delivery rates, tend to resemble those of the dominant culture.⁸ In the study by Janssen and coworkers, family physicians were more numerous than obstetricians in both hospitals (3:1 at the tertiary-care center and 12:1 in the community hospital). Although we can assume that family physicians delivered the majority of babies in the community hospital, the data in the study do not reveal what percentage of babies were delivered by family physicians in the tertiary-care center. Although more prevalent numerically, the family physicians may not have been (and probably were not) the dominant culture in the tertiary-care center.

Another recognized component of the institutional effect is nursing care style, with the likelihood of whether any given patient is delivered vaginally or by cesarean being directly related to the individual nurse caring for her. Some features of nursing care that may relate to patient outcome include the following: time spent with the patient, technique of fetal monitoring, nursing expectations, and the type and timing of analgesia offered.⁹

Patient demographics and expectations were examined in the study by Janssen and colleagues, and no differences were found. However, we do not know if patient expectations may have affected her choice of a care provider or her choice of a place of delivery. It makes sense that patients motivated to have less intervention and not wanting epidural analgesia would seek out the community hospital if the hospital’s usual practices were known to them.

Other questions to consider

Thus as Janssen and coworkers suggest, epidural analgesia may represent a proxy for a large conglomeration of other small parameters that do not themselves reach statistical significance. Most of these small parameters appear to be under human control, and it is in regard to them that we need to examine our attitudes and actions on behalf of our patients. Instead of examining our cesarean rates or our epidural rates, it may be more important to ask ourselves 2 questions: First, do we view labor and birth as natural processes? Second, do we base interventions on evidence that they will do more good than harm? We may never have the answer to “What is the right number of cesarean deliveries?”¹⁰ However, we are more likely to approach the right number by making sure we can answer the first 2 questions affirmatively than by agonizing over the statistics related to various parts of the patient’s care.

What about the babies? There was no statistically significant difference in the current study between APGAR scores at the 2 hospitals, indicating that the increased cesarean delivery rate at the tertiary-care center did not produce improved short-term infant outcomes for the low-risk patients as assessed by this one parameter. This is an often-repeated story. Other studies that have examined other parameters have shown that term, normal birthweight infants can have better outcomes at community hospitals than at tertiary-care centers, possibly related to the effect of the previously mentioned physician and institutional factors on their mother’s intrapartum care.^11-13

Conclusions

Janssen and colleagues make us think about our role as family physicians who provide maternity care and about what our patients should know. Although family physicians do have important maternity care roles in tertiary care centers as care providers, teachers, and role models, most of us provide care in community hospital settings. Although family physicians deliver approximately 20% of the babies in the United States, we deliver a much larger portion in smaller communities and are the main maternity care providers in rural areas. Providing this access is very important, since we know that pregnancy outcomes are poorer when maternity care is not available locally and women must travel for that care.^14,15 Modern medicine has fostered a “bigger is better” mentality, but this study and others like it provide evidence that where hospitals are concerned size matters in an unexpected way: Low-risk women and their babies may be better off in community hospitals than in tertiary-care centers.