The prevalence of injuries and fatalities in childbirth is among the most anguishing problems in health care.
The heartache of having a baby die or suffer injuries necessitating lifelong care is incalculable. Meanwhile, the potential liability for untoward outcomes
in delivery drives up doctors' liability insurance rates, prompting periodic warnings that obstetricians are being driven out of business.
But it turns out that solutions exist to preventing a significant percentage of the tragedies that cause all of this suffering and handwringing. A new Public Citizen report recounts childbirth safety initiative undertaken by four organizations in the past 15 years that have generated striking results.
Ascension Health reduced its neonatal fatality rate by nearly 50 percent across its 43 hospitals despite having a rate 62 percent below the national average at the outset of its initiative; New York-Presbyterian/Weill Cornell Medical Center reduced incidence of a brain injury caused by oxygen deprivation to 2 percent of the national average; Premier Inc., a health care alliance, reduced birth trauma among full-term newborns by 74 percent in the 16 hospitals participating in its safety initiative; and Hospital Corporation of America reduced maternal fatalities due to pulmonary embolism by 86 percent.
The methods used by these institutions were largely similar and fairly basic. Among them were conducting training in communications (breakdowns in
communication are implicated in 65 percent of catastrophic outcomes in childbirth); the use of simulations to practice handling emergency situations during deliveries; adoption of "bundles," which measure compliance with essential practices in high-risk procedures; and exercising greater care in deciding to go forth with cesarean section deliveries, which are risky and have soared in prevalence in the recent decades.
Litigation is an inexact proxy for safety because not all avoidable injuries are a result of negligence. But the programs cited in the report were remarkably successful at reducing litigation, as well. HCA, the nation's largest provider of obstetrics services, reduced claims by two-thirds. New York Presbyterian hospital reduced payments by 99 percent.
The safety practices highlighted in the report are not comprehensively adopted. Practice patterns in obstetrics are widely disparate, as are the quality of outcomes.
For instance, the use of cesarean sections varies by provider from 7 to 70 percent and women giving birth at low-performing hospitals are up to five times more likely to experience complications as those at high-performing hospitals. The stark improvements made by the organizations highlighted in the report provide cause for optimism that there must be great room for improvement at institutions that have not implemented safety initiatives.
The American Congress of Obstetricians and Gynecologists, the primary professional association of obstetricians, acknowledged in response to a question from Public Citizen that "adoption of updated and new best practices is variable across the country." ACOG called for "creating tools that will help us get from guidelines to implementation."
ACOG stopped short of endorsing laws or regulations to prompt implementation, but the obstetrics profession's ability to regulate itself appears limited. ACOG has since 1979 counseled against elective early deliveries, which are associated with significantly higher risks of complications. But these deliveries rose markedly until insurance companies, state governments and non-profit accreditation organizations began imposing an array of reporting requirements and financial penalties in recent years.
There are enormous cost savings to be realized by wider adoption of safety practices. Officials from the institutions highlighted in the report said that litigation savings dwarfed the costs of their safety programs. Meanwhile, merely reducing the rate of cesarean deliveries to the level recommended by the World Health Organization would save up to $441 million a year in California, alone.
But these benefits are just for starters.
Reducing neonatal mortality by 50 percent, as Ascension Health was able to do, would save 8,000 babies' lives per year.
How do you put a price tag on that?