BLUEPRINTS FOR BIRTHING

American hospitals with fewer unnecessary C-sections have one thing in common: better design

In the first half of the 2010s, one in three children born in the US was delivered through a Cesarean section. That hasn’t always been the case; in fact, C-sections have been rising since 1990, when only about 20% deliveries (pdf, p.1) in the US were done using the procedure.

While it’s hard to determine exactly how many C-sections are actually necessary, researchers generally agree the number is below 20%. According to the World Health Organization, it’s about 15%; other research says the optimal amount is as high as 19%—still, a lot lower than the US average. According to the Center for Disease Control (CDC), 55% of the C-sections performed in the US were elective.

But it’s difficult to make hard rules for when a C-section is required, as most decisions need to be made case by case. And, according to Neel Shah, an assistant professor at Harvard Medical School and director of the Delivery Decisions Initiative at Ariadne Labs, who does research on the C-sections epidemic, it’s nearly impossible to isolate which C-sections were necessary and which were not after the fact. Largely that’s because the decision to perform a C-section is usually confirmed by the outcome, whatever it is: a healthy baby delivered through a C-section is proof that the surgery was successful; a suffering baby is the proof that it was needed.

At best, an excess of C-sections is a waste: as a surgical procedure (the most common in America), it requires more resources and costs more than a natural delivery, leading to annual losses of about $5 billion in the US.

Worse, unnecessary C-sections increase the health risks of having a baby. Hemorrhage, cardiac arrest, and major infection occur three times more often in women who have surgical deliveries. And after a woman has had a C-section, her following deliveries tend to occur in the same way, accentuating the risk of placenta accreta (table 1), a potentially fatal condition which occurs when the placenta grows too deeply into the uterine wall, because of excess scar tissue in the uterus.

Uncovering the cause of rising C-section rates

There’s also no simple way to answer the question of why C-sections are rising in the US. Shah points out that there are some economic incentives: doctors may be slightly more inclined to perform C-sections because they get paid more for it. The same may be true for hospitals and clinics, which make more money from surgeries than natural deliveries.

Then there’s the matter of time. According to Shah’s latest report, made available online today (March 21), the average vaginal delivery requires about 20 hours of medical attention, compared to just two for a typical C-section. This, writes Shah, feeds into what he calls a “pressure tank model”: limited resources, high workload, and/or limited motivation and accountability all increase the pressure on doctors to move patients through the system faster, which may lead to unnecessary C-sections.

Key medical practitioner organizations, including the American College of Obstetricians and Gynecologists and the American College of Nurse Midwives, have urged physicians to have greater patience during the various stages of labor. But, Shah says, rarely do they offer guidelines that address the root causes of impatience, which has “less to do with the clinician and more to do with the environment around the clinician.”

“In the US,” says Shah, “the hospital a woman chose is the major risk factor of having a major surgery,” such as a C-section. Collecting data on C-sections in the US, Shah observed that the ratio of C-sections in hospital can change very dramatically—from 7% to 70%—and when a gynecologist worked in more than one facility, the number of C-sections he or she performed seemed to vary quite significantly from one facility to the next.

What if, Shah thought, C-sections were happening by design?

Designing our way out of the epidemic

Working with a team from the MASS Design Group, a Boston-based design firm specializing in hospital and health care design, and the Robert Wood Johnson Foundation, a philanthropy focused on healthcare improvement, Shah and his team at Ariadne Labs set out to test whether architectural and design features impact childbirth decisions.

The team investigated 12 different facilities around the country: three freestanding birth centers, four community hospitals, three academic hospitals, one women’s hospital, and an Native American health services hospital. Across these facilities, C-sections rates range from 5.1% (a freestanding birth center in Nashville, Tennessee) to 34.9% (a community hospital in Princeton, New Jersey).

The research, published in a report titled “The impact of design on clinical care in childbirth,” bore out the hypothesis: Shah found, for example, that hospitals with lots of births and a low number of rooms usually had more C-sections, because they are “a way to move people through faster,” he explains.

In addition, they found that most of the labor wards were designed for surgery—and not natural labor, which can take hours and even days. “If you go to a cardiac ICU [intensive care unit] and a labor ward, you won’t find much difference,” says Shah. Even small details like the position of the bed in the room are telling: instead of being in the middle of the room—set up for a woman who’ll be there for hours and will need help pushing—the bed is often up against the wall, ready for the patient to be hooked up to monitors and medical equipment.

But the data reveal some key design aspects that can be applied to labor wards to lower C-section rates. A few examples:

  • Having a larger “circulation space,” where women in labor can walk around, which helps natural delivery.
  • Reducing the distance between patients’ rooms saves medical personnel time, freeing up resources to give mothers in labor the attention they require.
  • Keeping labor support tools (such as birth balls or birth stools) within the patient’s reach speeds up natural delivery.

In addition, the institutional patience needed to support natural delivery can be nurtured by a “labor floor [that] can adapt to unpredicted surges in patient volume or acuity,” says Shah, “by flexibly recruiting critical resources such as nurses and beds.” Essentially, facilities that can expand and contract rapidly—by, for instance, being able to call more nurses on to duty when there are a lot of deliveries—have an easier time dealing with the unpredictable schedule dictated by natural births.

Traditionally, the capacity of a care center is measured in beds, but natural birth frequently means the facility has to “admit someone who doesn’t need a bed right away,” Shah says. That means—perhaps counterintuitively—that they need less beds than patients, because a woman in labor doesn’t immediately need to lay down. “When it comes to facility planning, [that] blows the designer’s mind,” says Shah.

On the flip side, the data show that some design choices traditionally considered optimal are in fact detrimental. For example, standardized “same-handed” rooms—where beds and medical tools are placed on the same side of the room—were not found to make medical personnel’s job easier, and may not be worth investing in during future facility buildouts and renovations.

Shah’s team and MASS are now expanding the pool of facilities in their research project to 30-50. Ultimately, their goal is to develop a true “evidence-based” design approach for birthing centers: a series of recommendation and design changes to implement to set up a care environment that promote natural birth over C-sections by helping doctors and nurses better do their job.

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