Real data

Why we all need to know how many C-sections each hospital in India is conducting

The rising number of c-section is driven not by necessity but by hospital profits or convenient schedules.

A petition to make it mandatory for all medical institutions to publicly declare their percentage of Caesarean sections against all live births in that facility has elicited heated discussions. The Minister for Women and Child Development Maneka Gandhi has supported the move while some doctors have protested it. In fact, the World Health Organisation recognised the need to make such numbers public in a statement in 2015.

The number of C-section deliveries has been rising across the world and an expert panel met in October 2014 in Geneva to deliberate on this trend. They revisited the recommended WHO norm of keeping c-section rates at between 10% and 15% – a figure that was arrived at in 1985 on the basis that maternal and infant mortality improves as the percentage of C-sections rises to about 10%.

After reviewing country-level studies and analysing worldwide data, this panel agreed that while no woman who needs a c-section should be denied access to it just to maintain a particular rate, neonatal or maternal mortality rates in a population did not decline further when C-section rates rose above 10%. In other words, saving lives cannot be cited as the primary cause for Caesareans when the rates cross the 10 to 15 per cent mark. The expert panel confirmed and reiterated the 1985 norm.

The number of C-section for a region or country gives important information about access to life-saving interventions and emergency obstetric resources, which is critical to maternal health. Health systems can, however, be overburdened if expensive interventions like C-sections are performed when they are not absolutely needed. This also affects equal access to healthcare across all sections of a society. Thus, monitoring macro-level data on C-sections rates for an entire population helps policymakers.

However, data required to make these macro-level calculations are generated at a micro-level or at the level of individual medical facilities. In order to compare trends and find solutions, a standardised system of data generation must be followed. The WHO has provided this standardised system in the form of the 10 group Robson classification that helps doctors classify the C-section surgeries along five distinct parameters – whether the woman is giving birth for the first time or has given birth previously with or without a C-section, the onset of labour, whether the foetus has come to term, the position of the foetus and whether there is more than one foetus.

Every woman undergoing the surgery can be classified along these parameters, making the data easy to assess and compare. Whether at the secondary or tertiary level of care, this data clearly tells us whether clinical management protocols are followed in a facility. The WHO also recommends that the results of the Robson classification categories be available to the public, as does the petition to the government.

The information gap

National Family Health Survey data clearly reveals that the percentage of C-section births is higher in the private facilities across states. The pressures of profiteering, the convenience of being able to schedule a birth or sometimes even have a baby born at an “mahurat” or auspicious time can supercede medical requirement and turn a regular vaginal birth into a surgical event. C-sections have becomes so common that instead of being a life-saving, emergency recourse, it is now being accepted as the new “normal” and a supposedly pain-free, risk-free, modern way of childbirth. This perception is the result of a huge information gap. Few are aware the mother faces risks of excessive blood loss, blood clots, heart attacks, difficulty in breastfeeding and increased chances of repeat c-section births. The baby has higher risk of asthma, obesity and diabetes. Unfortunately, when doctors discuss risks associated with childbirth only selectively, mothers cannot make informed decision. This gap needs to be addressed by making information easily and publicly available.

A Harvard Medical School report by assistant professor Dr Neel Shah states that an important determinant of whether a C-section is performed “may simply be which hospital a mother walks into to deliver her baby”. If each hospital published its c-section trends, a mother might be able to make a better informed decision. Declaring data publicly and providing the midwifery model of care, have been identified as key factors in reducing avoidable interventions during childbirth.

The biggest challenge is to ensure reproductive health without compromising the reproductive rights of women. Women’s felt experiences of pregnancy and birth are often undermined. Even WHO acknowledges that there is lack of evidence of the relationship between the mode of delivery and psychological and social wellbeing of women. From being a life-event, birth is now treated like a disease. Alienating women from the experience of birth facilitates control over women’s bodies and choices and the mechanism of power is “technology”. While technology is important and potentially life-saving, using technology as a blanket response cannot work.

More than just medicine

Fertility, reproduction and birth have always been a socially-defined territory. The socio-economic, political and cultural conditions in which technology is used make a big difference. In a culture where silencing is a part of socialisation, voicing one’s need for information to protect the right to informed consent, autonomy and self-determination during childbirth may seem like a war cry to many. It is a challenge to an elite club that believes that it has exclusive rights over information about medically-assisted childbirth.

It is high time that women’s voices get heard and women are put at the centre of maternity care, everywhere. The petition to declare c-section rates of medical facilities is rooted in the concern about heightened intervention and increasing costs, but it does not seek to destroy the fine balance defining the symbiotic relationship between care-providers and care-seekers. This may well be a significant step for medicine to look beyond the scientific and become more social.

The writer is the petitioner who has asked for all hospitals to publicly declare their Caesarean section percentages. She volunteers for the NGO Birth India and is a scholar at Research Centre for Women’s Studies, SNDT Women’s University.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.