Nikkipowerpoint For Epi

Geographical Variations among Age-Adjusted
Low-Risk Primary
Cesarean Section (CS) Rates in California

Nikki Stoddart
Masters Candidate
Division of Epidemiology
Department of Health Research and Policy
Stanford University, School of Medicine

: Transforming Maternity Care

A Brief History of Cesarean Birth

The Birth of Asclepius
1549 Alessandro Beneditti
“De Re Medica”


Origins of Cesarean Birth
 Historical record indicates infants born via
Cesarean
 GreekMythology: Apollo removed Asclepius
from Coronis’ abdomen
 Procedure performed on living women in
Ancient China


Suetonius 1506 Woodcut
Lives of the Twelve Caesares


Why is it Called “Caesarean”?
 Named for the birth of Julius Caesar?
 Unlikely because in ancient Rome the
procedure was done only when the mother
was dead or dying but Caesar’s mother,
Aurelia, lived to hear of his Conquest of
Britain.


Oh, I see….
 Possibly from the Latin “caedare”,
meaning “to cut”
 Roman Law stated that women dying in
childbirth must be cut open to remove the
infant.
 Latin word “caesones” refers to children born
by postmortem incision.


Finally, we have a live one!
 In 1500 Jacob Nufer, a Swiss pig gelder,
performed a Cesarean on his ailing wife.
She lived to be 77 years old, and birthed 5
more children vaginally, including a set of
twins.


But Still Gruesome….
 Between 1787- 1876, not a single Parisian
woman survived the Cesarean operation.


Performing Abdominal Surgery in Street Clothes
Thomas Spencer Wells, Diseases of the Ovaries, 1872


From Fatal to….....Less Fatal
 Maternal mortality rates dropped in the
mid nineteenth century
 1846 William Morton- Diethyl Ether
 Women less likely to die from shock
 1860’s Josef Lister- Carbolic Acid
 Antiseptics and the germ theory


From Less Fatal…… To Safe
 C/S rates increase because:
 Post WWII, many new hospitals built
 Surgical technique improved
 Spinal Anesthesia developed
 Penicillin purified 1940
 Roman Catholic religious concerns


From Safe……to Every Day
 Continued rate increase far outpaces rise in birth rate
 Convenience
 Physicians can schedule around vacations, dinnertime
 Women can schedule time off from work
 Cutting loses (Better a section a 6pm than a delivery at 3 am)

Culture
 “Too Posh to Push” – Victoria Beckam
 Vaginal Preservation Society

 C.Y.A.
 Malpractice suits
 twins , breech, or VBACs are too risky


 Technology in the Labor Suite Strongly Correlates with CS rates
 Labor induction
 r= 0.57 (P<.0001)

 Fetal monitoring
 Early Labor Admission
 “Failure to progress” leads to CS

 r= .62 (P <.0001)


 Financial
 Ob/gyn’s must do more deliveries to pay MI
 C/S birth reimbursement is higher than
vaginal


So, where does that leave us
Today?
 WHO and USDHHS recommend no more
than 15% of all births be C/S
 Beyond 15%, risks begin to eclipse benefits
 Yet 1/3 women in CA deliver via C/S


For every 5% decrease in the national
primary CS rate there will be:
 Between 14-32 fewer maternal deaths
 33,000 fewer NICU admissions
 An savings of $750 million -$1.7 billion in
healthcare costs.
Plante 2006


Risks of CS to Mother
 Blood Loss/Transfusion ≥ 1000 ml
 Postoperative Infections
 Subsequent Infertility
 Subsequent increased risk: placenta previa, placenta accreta, placental
abruption and hemorrhage
 Injury to bowel, bladder, pelvic vasculature
 Rehospitalization
 Maternal Mortality
 RR: 1.6- 2.8


Risks of CS to Fetus
 Higher rates of respiratory distress
 5% C/S
 0.5% vaginal

 Possible iatrogenic prematurity
 Double risk of NICU admission
 Double risk of unexplained stillbirth in
subsequent pregnancy


Objectives
 Identify regional variations of Age Adjusted Low-
Risk C/S rates in California
 Simplify regions: Northern, Southern CA and LA
County
 Identify excess rates of C/S deliveries
(Exclude Hospitals with less than 100 births per year)
 Inform hospital leaders; lead quality change


Low-Risk Primary Cesarean Section
Defined:

 Number of Cesarean Deliveries per 100 deliveries
among women who have not previously had a Cesarean
section (excludes abnormal presentation, preterm, fetal
death, multiple gestation, and breech procedures)
Primary C/S rates are age-adjusted.

OSHPD Data 2006


Age-Adjusted Low-Risk Primary C/S
Rates distributed to quintiles and
applied to regions:

 0-20%; (Quintile 1: 5-13)
 20-40%; (Quintile 2: 14-15)
 40-60%; (Quintile 3: 16.1-16.9)
 60-80%; (Quintile 4: 17-19)
 80-100%;(Quintile 5: 19+)

Quintile ranges are per 100 births

Top and Bottom two Quintiles (40%) of Age-adjusted
Low-Risk Primary C/S Rates: Northern CA
Hospitals with rates > 17 Hospitals with rates < 16
n = 32/124 (25%) n=74/124 (60%)


Top and Bottom two Quintiles (40%) of Age-Adjusted
Low-Risk Primary C/S Rates: LA County CA

Hospitals with rates >17 Hospitals with rates < 16
n=44/60 (73%) n=12/60 (20%)


Top and Bottom two Quintiles(40%) of Age-Adjusted
Low Risk Primary C/S Rates: Southern CA

Hospitals with rates >17 Hospitals with rates < 16
n=34/80 (43%) n=40/80 (50%)

Hoag memorial

Scripps La Jolla


Public Health Implications of Cesarean on Demand
Lauren Plante 2006


What are the total regional excess
cases above California’s mean primary
C/S rate (16 per 100 live births)?


Excess Cases of Low-risk
Primary Cesarean Births (age-adjusted)
above the State mean of 16 per 100 births.
By Hospital
San Francisco Bay Area 2006

Total Excess C/S Cases= 349 (3%)
Total low-risk non prior C/S= 11,043 (11%)
Total Live Births= 97,000

Good Samaritan
San Jose

Hospitals with more than 200 Excess Cases are labeled

above the State mean of 16 per 100 births.

By Hospital, LA County 2006

Total low-risk non-prior C/S= 22,327 (20%)

Valley Pres

Cedars Sinai Hollywood Pres
Garfield Citrus Memorial
Huntington Park


above the State mean of 16 per 100
births.
By Hospital, Northern CA 2006

Total Non-Prior C/S= 23,745 (11%)

Good Samaritan San Jose

Hospitals with more than 200 Excess Cases are labeled

Birth Costs (In thousands)
20000
18000
16000
14000
12000
10000 Vaginal Birth
8000 Cesarean Birth
6000
4000
2000
0
Physician Cost Hospital Cost Total Cost


Financial Implications of California’s
Excess Cases (Complications excluded)
 Total excess cases above state mean:
 17,677
 Excess Healthcare Costs per Annum:
 $ 93,422,945.00

 Total excess cases above 15 (WHO Recommendation):
 40,654
 Excess Healthcare Costs per Annum:
 $214,856,390.00


Conclusion:

 Next Steps?

 Questions/Comments?
 What benchmark should we use?
 Is Geomapping a useful tool for sharing data?


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