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Childbirth Complications: Some Hospitals Have 5 Times More, But Which Ones?

By Richard Knox

The risk of a major complication of childbirth can be up to five times higher at one hospital versus another, a new study finds. But there’s no way expectant mothers can tell the high-risk hospitals from the low — at least, not yet.

A study in this month’s Health Affairs is the first ever to examine hospitals’ childbirth complication rates on a national basis. Authors looked at a representative sample of more than 750,000 deliveries that took place in 2010 at hospitals large and small, urban and rural, including both teaching and community institutions.

Major complications include hemorrhaging, infections, vaginal lacerations and blood clots. Unlike major complications from, say, cardiac surgery, these obstetrical glitches are not generally life-threatening.

On the other hand, as Dr. Laurent Glance, the study’s lead author, tells CommonHealth: “The vast majority of women of childbearing age are fairly healthy people. They can reasonably expect to have a baby without any complications.”

The study found that for women delivering vaginally, the risk of a major complication can be more than double at a “low-performing” hospital (23 percent) than a “high-performing” institution (10 percent).

When it comes to cesarean deliveries, the disparities are even greater — 21 percent at a low-performing hospital versus a little over 4 percent at a high-performing obstetrical unit.

The study doesn’t provide Massachusetts-specific complication rates, but the researchers found no significant differences between Northeast hospitals and other regions. “It’s reasonable to assume there is a similar amount of variation [among Massachusetts hospitals], but we can’t say for sure,” Glance says.

If you think of the results in a big-picture way, it means that among the roughly 4 million American births a year, hundreds of thousands of women could avoid childbirth complications if somehow low-performing hospitals could raise their outcomes to those of their betters. Extrapolating from the new study, about 520,000 new mothers suffer a major complication.

The wide disparities in childbirth complications care are especially striking when you consider how big a slice obstetrics represents of the total health care pie.

Childbirth is the most common reason for hospitalization, accounting for nearly one in every four discharges. Cesarean delivery — the way one in every three American babies is born these days — is the nation’s most common operation. Childbirth is a $100 billion-a-year enterprise.

And yet until now, nobody has looked at childbirth outcomes on a national level.

Dr. Barbara Levy, vice president for health policy at the American College of Obstetrics and Gynecology, or ACOG, says this is partly because most government efforts to examine health care outcomes has focused on Medicare, which covers the elderly and disabled.

And hospitals themselves “don’t invest a lot of effort in women’s health programs” such as obstetrics, Levy tells CommonHealth. “They see them as loss-leaders, not income-generators. So resources have not been invested in women’s health care in general. It’s very frustrating.”

Levy says she wasn’t shocked to see such wide disparities in obstetrical complication rates.

“We understand there are disparities, it’s not a surprising finding,” she says. “Any health care service we’ve looked at, we’ve seen large disparities — cardiology, joint replacement, appendectomy, or any major service area. Although we pay a huge amount for health care, we’re not getting the care we deserve.”

The new study, in fact, is a first step in a strategy to reduce disparities in the quality of obstetrical care.

ACOG is working with the study’s authors and others to extract data from women’s electronic medical records — a federally mandated innovation for all U.S. hospital patients — so that complication rates and outcomes for both mothers and infants can be routinely compared across institutions.

"[P]atients and families want to know more about the hospitals and physicians caring for them."

Dr. Laurent Glance

It’s called the Maternal Quality Improvement Project, or MQIP. It should give a more fine-grained picture of complications and their consequences.

For instance, it might help explain one finding of the new study: Hospitals with higher cesarean rates have lower complication rates for women having either a vaginal or surgical delivery.

Levy says it may just be that hospitals that do more cesareans are naturally likely to have fewer vaginal tears, or lacerations. “That wouldn’t make me want to choose one hospital over another,” she says. “In fact, I might choose a hospital with a lower cesarean rate but a higher rate of lacerations.”

She says a pilot version of MQIP, involving 100 hospitals, should be up and running by the end of this year. It will take a couple more years, at least, to roll it out nationally.

Glance says experience in other fields, such as cardiac surgery, shows that telling caregivers and their institutions how they rate compared to the competition “gives people a huge incentive to improve, because we’re all extremely competitive people.”

But even when MQIP is routinely giving performance ratings to obstetrical caregivers, ordinary consumers won’t necessarily be able to find out how their nearby hospitals are doing. It will be up to individual hospitals to decide whether they want to share that sensitive data.

Glance is optimistic that public report cards are coming. “I think we’re at a tipping point,” he says. “I think people get it that patients and families want to know more about the hospitals and physicians caring for them.”

Levy agrees that public disclosure will eventually happen. “As hospitals gain confidence in the data, they will choose to voluntarily report,” she says. “And that will create peer pressure on others to report.”

And there will be public pressure to know how obstetrical units are performing. Earlier this year, WBUR’s Martha Bebinger reflected that need-to-know in a series that pulled together available public data on obstetrical care.

Bebinger’s series revealed variations among Massachusetts hospitals on such indicators as cesarean rates and early elective deliveries (a practice frowned upon by many childbirth authorities). If MQIP works the way its architects intend, a future series will have a lot more data to share.

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