5 Measures To Compare Childbirth At Mass. Hospitals

Childbirth is one of the most important medical events of our lives, if not the most important. We want to make sure our moms and babies get the best possible care. But we often choose that care based solely on reputation or word of mouth.

A WBUR data analysis aims to offer more. We’ve pulled together childbirth quality data that, for the first time, enable pregnant women and their families to compare hospitals across Massachusetts.

Much of this information is public, but it’s scattered here and there or buried in state reports. WBUR also collected data from the 47 hospitals in Massachusetts that deliver babies.

What We Measured

After consulting medical experts and moms, we selected five measures to compare hospitals that perform deliveries in Massachusetts:

1 – Early elective deliveries (source, collected and shared by The Leapfrog Group)
2 – First-time Cesarean sections (source, pages 84-85)
3 – Vaginal births after a C-section, or VBACs (source, pages 84-85)
4 – Episiotomies (source, collected and shared by The Leapfrog Group)
5 – Exclusive breast-feeding (source: collected by WBUR).

(We did not include some mom-friendly measures — jacuzzis, private rooms or 24-hour help with breast-feeding — because it’s hard to collect this information consistently for each hospital. But we want to make sure patients help drive this quality movement, so fill out our survey and we’ll make sure your preferences are part of this public record.)

How We Chose These 5 Childbirth Measures

We started by asking childbirth quality experts: What do you want to know about hospitals that deliver babies? We heard the same answer again and again: Hospitals should not be scheduling early deliveries unless they are absolutely necessary. Babies need the full 39 weeks in the womb.

“There is a national movement, because there has been an overuse of this procedure, to reduce early elective deliveries,” said Celeste Milton, associate project director in the Center for Performance Measurement at The Joint Commission, a national group that accredits hospitals. She leads a project at The Joint Commission that will begin collecting information on five childbirth quality items, including early elective deliveries, next month.

Many hospitals in Massachusetts have committed to ending early elective deliveries and some have reached zero, but most are not there yet.

Our second measure, first-time Cesarean sections, is more controversial in part because it has become so common. A C-section requires incisions in the mother’s abdomen and uterus and “costs more money [and] increases length of stay,” Milton said. She added that “there can be increased risk with having a surgical procedure.”

Milton says it’s important to look at how often hospitals perform C-sections, especially for first-time moms. If they have a second or third child, those deliveries are also likely be C-sections. The chances of rupture and bleeding increase with each subsequent birth.

Childbirth quality expert Carol Sakala has another reason hospitals should avoid C-sections: They may increase a baby’s risk for chronic diseases. “So far they are asthma, allergy, obesity and type 1 diabetes,” she said, “all roughly 20 percent increased likelihood for Cesarean-born babies.”

Our No. 3 measure, vaginal births after a C-section (VBACs), is of interest to many mothers.

Sakala helped the National Quality Forum, a nonprofit that reviews and endorses quality measures, create a list of ways to assess a good birth. Our fourth and fifth measures come from the nonprofit’s list.

An episiotomy is a cut made by a doctor to enlarge the mother’s vaginal opening during birth, a practice that has grown out of favor among younger obstetricians. And exclusive breast-feeding measures the percentage of babies fed nothing but breast milk while in the hospital.

In the end, we chose the five measures based on what experts say is important, available data and what pregnant women say they want to know. Sakala says if there is any group of patients that will use quality information to shop for the best care, it’s pregnant women.

“They’ve got nine months or so to investigate and take charge and plan,” she said. “If we can help childbearing women to have a sense about becoming savvy health care consumers, they can go on to make wise decisions in other areas.”

What Expectant Moms Said About The Findings

Four then-expecting moms who reviewed our childbirth quality data at WBUR. From left: Betsy Deitte, Sara Tucker, Sutanuka Lahiri and Rebecca Loveys. (Martha Bebinger/WBUR)

Four then-expecting moms who reviewed our childbirth quality data at WBUR. From left: Betsy Deitte, Sara Tucker, Sutanuka Lahiri and Rebecca Loveys. (Martha Bebinger/WBUR)

When you take a look at the information we do have about childbirth quality, you’ll notice big differences among hospitals. Last year, we spoke with four then-pregnant women who reviewed the data at WBUR’s studios.

“The episiotomy rates are terrifying,” Betsy Deitte, who was pregnant with her third child, said with a nervous laugh. Many doctors will tell you an episiotomy is a thing of the past. But that’s not what the numbers show.

Deitte remembered that women generally heal faster from a natural tear.

“The fact that at some of these hospitals a third of women are getting an episiotomy seems not very helpful as far as getting a woman to heal and feel better sooner,” she said.

Our four moms-to-be didn’t care too much about early elective deliveries. First-time C-section rates, where there’s a big spread among hospitals, did catch their attention, however. But Sara Tucker, a first-time mom from Quincy, was uncertain about the numbers.

“With C-section rates you never know what’s behind those numbers,” she said. “Those could all be C-sections that needed to happen.”

Hospitals do not report which C-sections were medically necessary, but it’s widely accepted that most hospitals perform too many of them. The World Health Organization says no hospital should be doing more than 15 percent of births via a C-section because higher rates are not linked to any benefit for the mother or child.

Our analysis finds that all but four hospitals in Massachusetts are doing more than 15 percent.

Sutanuka Lahiri, who was expecting her first child, wanted to know why. “I wish these numbers had age, complication and why [somebody would] just choose C-section,” she said.

Hospitals don’t offer that information.

There’s also a dramatic difference in the rate at which women go back to a vaginal delivery after having a C-section.

And finally, breast-feeding. Experts are beginning to check the percentage of women who intend to breast-feed and succeed, at least while in the hospital.

Deitte said asking who succeeds isn’t helpful.

“‘How much time do you have with a lactation consultant?’ ” is what Deitte would ask. “I feel like that would be way better” to help women breast-feed, she said.

“Or, if [the lactation coaches/consultants] are actually there in the hospital,” Lahiri said.

“Available, 24/7,” added Rebecca Loveys, another expectant mother.

Lahiri and Loveys wanted hospitals to send breast-feeding coaches to their homes.

“That’s when the problems really come up,” Loveys said, “when you go home and you’re clueless. Your baby is crying and you’re afraid your milk hasn’t come in, you need to call [coaches] and cry.”

These moms felt strongly that insurance should cover the cost of breast-feeding coaches, as well as doulas — birthing coaches — to help during and after birth. And they all nodded in agreement when Loveys said she wanted a hospital that will follow her direction.

“For me, it’s just important that the support is there,” Loveys said.

Lahiri said looking just at hospital quality information may not be helpful for many women because their “doctor kind of advocates where you finally end up.” She and Deitte cautioned that quality numbers for a hospital wouldn’t tell you everything you’d need to know about where you’d be comfortable delivering your baby.

“To me,” Deitte said, what’s “more important than a hospital’s C-section rate is your relationship with the practice and what’s going to happen.”

Loveys nodded. ”Yeah, your care provider, it’s really important to ask those questions before you end up in labor.”

Loveys asked a lot of questions and factored in some of the things experts say are important. In the end, though, she chose based on comfort and went to the hospital with the best birth tub and no limits on how long she could stay in it.

Clockwise, from top left: Elliot Brian Deitte, Gavin Samuel Rivera, Zachary Samuel Kneece and Saina Ganguly. (Courtesy)

Clockwise, from top left: Elliot Brian Deitte, Gavin Samuel Rivera, Zachary Samuel Kneece and Saina Ganguly. (Courtesy)

“They said, ‘You can get in the tub whenever you damn feel like it,’ ” Loveys said, laughing. “And so that was like, ding, ding, ding, we got a winner.”

Loveys chose Mount Auburn Hospital, in Cambridge. Deitte selected Newton-Wellesley Hospital. Tucker and Lahiri both picked Beth Israel Deaconess Medical Center in Boston.

There is also a big difference in the cost of deliveries among the state’s hospitals. Insurers are required to quote you a price online or on the phone. The same requirement extends to hospitals, as of Jan. 1.

There is no way yet to compare the quality of individual physicians or midwives, but if you want to see how hospitals measure up when it comes to childbirth, we’ve got the numbers.

Note: Following our conversation, Loveys, Deitte and Tucker all delivered healthy boys — Zachary, Elliot and Gavin, respectively — and Lahiri delivered a daughter named Saina.

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  • cambridgeres

    This data is from 2010, and a number of advances have happened in many of the hospitals mentioned. It is deceptive to use numbers from over 3 years ago as a reflection of the current state of the hospital’s L&D practices.

    • Martha Bebinger

      Hi Cambridgeres – I completely agree. When the state releases the 2011 data later this year (yes, three years later), we will “update” our chart.

  • reinzig

    It seems somewhat irresponsible to discuss the rate of c-sections without discussing the well established relationship between the need for c-sections and the interventions that have become routine in hospitals (pitocin drips, other means of inductions, epidurals). These are NOT independent variables.

  • helloshannon

    love this series! I delivered at Mount Auburn with my first and will again with my 2nd this April. had a great experience. The episiotomy rate doesn’t seem like a big deal to me but that’s probably because my son’s fat head was stuck for 3 hours so any help I could get I gladly took!

  • Jessica Homa Greenwood

    Jordan Hospital (recently acquired by BID) added VBAC support after the data was published. South Shore expectant moms have another option for VBAC’s!

  • EverPerfectUnion

    Of course the main story here is not the measures being used which will evolve as patients become more aware. The main story is how you can actually get hold of such data. The question I have is why is such data not required to be disclosed by the Centers for Medicaid and Medicare. What are the guidelines and regulations regarding disclosure of quality measures by healthcare providers? Maybe Dr. Berwick can tell us.

  • Mike

    Great piece!

  • Chris Just

    Regarding metrics, it’s true we have to be careful we are not comparing low risk births to higher risk situations that require more intervention. However, when comparing only low-risk births in different settings we still still see disparities. For example, take a look at the National Birth Center II study which, according to ACNM’s news release, included “more than 15,500 women who received care in 79
    midwife-led birth centers in 33 US states from 2007 through 2010 & found
    that fewer than one in sixteen (6 percent) of participants required a
    cesarean birth compared to nearly one in four (24 percent) similarly low-risk women cared for in a hospital setting.” These findings included improved outcomes and lower cost for care.

  • EngineerGirl

    I think this article is misleading and I really question the metrics used. Perhaps the high rate of c-sections are due to high numbers of ask risk patients. An episiotomy saved my first daughter’s life and I was so ill at the birth of my second child it was impossible to breastfeed exclusively.

    • Martha Bebinger

      Hi engineer girl. Believe me, if I could get data that takes risk into account when comparing C-sections, I would post it. The Joint Commission has just started collecting C-section rates narrowed to babies that were positioned for a normal vaginal delivery. I don’t have word yet on whether the Joint Commission will share this data or when.

      A study out of the Harvard School of Public Health found that C-section rates still vary widely (almost three fold) even when just comparing babies positioned for a normal vaginal delivery. Here’s a link: http://dash.harvard.edu/bitstream/handle/1/10508051/hospital_differences.pdf?sequence=1

      And by the way, we’ll have a story on the differences in C-sections rates, comparing two hospitals in the Boston area tomorrow.

  • reinzig

    It’s really too bad that this piece starts off, in its very first sentence, with a fallacy. Birth is not a medical event.

    • AMC

      I thought the very same thing. Why C-section and not Cesarean birth? A Cesarean is the birth of a child.

    • Martha Bebinger

      Reinzig – I get your point, but when a woman gives birth in a hospital, isn’t that a medical event? We’re comparing the quality measures in hospitals.

      • Mike

        Birth can occur at home or in a hospital and a midwife is usually present. When medical complications (or suspicion thereof) require a medical doctor to be involved (this will mostly be at a hospital) it will be moving from “non-medical” to “medical”. Again in many other countries childbirth will not happen at a hospital at all. So I would agree that the idea that childbirth is a “medical event” is not completely accurate.

      • reinzig

        No. Not necessarily. There is–and has been for many years–a trend toward birthing centers in hospitals in which birth remains a very non-medical, natural, event. Many people choose such settings to be near medical care in the event that they do need medical assistance….but so many of them do not. To many people, the presence of an in-hospital birthing center, staffed largely by midwives, that does not regard birth as a medical event and does not treat it as such, is a strong, if not the strongest, measure of quality in the hospitals they may be considering.

    • Megan

      I am so glad someone said this. As someone who has birthed a baby naturally at home, I felt the very same way when I heard the intro to this piece. Birth is a natural bodily function, not a medical event. It has BECOME a medical event to the detriment of many women because of how our healthcare system works. I wish this idea was more a part of the discussion here. Why aren’t home birth or birth center statistics discussed?

      • Rachel

        “Maternal mortality in the United States has declined dramatically over the past century. The rate declined from 607.9 maternal deaths per 100,000 live births in 1915 to 12.7 in 2007.”

        That’s a 98% decrease in under 100 years. You can argue whether over use of c-sections is +/-15%, but to say that the medicalization of birth has been “to the detriment of many woman” I think misses how much benefit we have gained from that same medicalization.

        Source:
        http://www.hrsa.gov/ourstories/mchb75th/mchb75maternalmortality.pdf

        • Megan

          Hi Rachel, I don’t disagree that there are benefits to having available medical measures and technologies that save women’s and babies lives in circumstances where something goes wrong with labor. However, for the majority of women, birth would proceed naturally and safely without intervention. It is the unnecessary interventions that so often cause harm to both babies and mothers. In fact, in the U.S., we have the highest maternal mortality rate in the developed world. As reported in today’s follow-up article on WBUR about C-section rates in Mass hospitals, the research shows we have a RISING maternal mortality rate. It’s hard to make sense of the discrepancy between your source and this one, but it is something to consider. Thank you.

        • reinzig

          Medical care (for any and all conditions), infection control, prenatal care, and nutrition have undoubtedly improved drastically between 1915 and 2007. No one is arguing that, for women who need medical intervention, the advancements have not been highly beneficial. There is, however, abundant evidence that “normal” birth that does not need medical intervention (which is the great majority of births) has been dramatically overmedicalized in the last 20 years, often to the detriment of mothers and babies.

  • MITBeta

    I heard this story on the radio this morning and it made me so sad for first time parents everywhere. How can you make a good decision about where, with whom, and under what conditions you want to deliver your baby if you don’t even understand how the system works?

    While I’m in complete agreement with the metrics they are using to rate hospitals, the numbers are a little bit like saying, “People get fat because they eat too much,” without ever stopping to consider WHY that might be. Why do some hospitals have lower C-section rates than others? Also, the numbers talk about the hospital, but there might be many different practices with privileges at a given hospital — maybe one practice drags the averages way up or down.

    If only there were people who really took the time to get to know expectant mothers, understand their needs and desires, and shephard them through the system, whichever path they choose…

    Oh, wait: Support your local midwives and doulas.

  • culturecarousel

    As a first time mom expecting my first this April, I am thrilled that WBUR undertook collecting this data and presenting it in such a user-friendly way. It reaffirms my decision to deliver at Cambridge Hospital. Of course data only tell us so much. For instance, I am wondering for those hospitals with very low c-section rates, might it be due to the fact that complicated deliveries are transferred to larger medical centers with level 3 nursery facilities and more robust NICU departments? Probably such data is not tracked, but it’s food for thought. Thanks WBUR and participants!

    • Martha Bebinger

      Hi culturecarousel – we’ll have a story about reasons for the big range in C-sections tomorrow – but you are right – the transfer of complicated deliveries to larger teaching hospitals is a factor. Good luck!