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Nikkipowerpoint For Epi

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Thesis Presentation on Rates of Primary Cesareans in California.

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Nikkipowerpoint For Epi

  1. 1. Geographical Variations among Age-Adjusted Low-Risk Primary Cesarean Section (CS) Rates in California Nikki Stoddart Masters Candidate Division of Epidemiology Department of Health Research and Policy Stanford University, School of Medicine : Transforming Maternity Care
  2. 2. A Brief History of Cesarean Birth The Birth of Asclepius 1549 Alessandro Beneditti “De Re Medica” : Transforming Maternity Care
  3. 3. Origins of Cesarean Birth  Historical record indicates infants born via Cesarean  GreekMythology: Apollo removed Asclepius from Coronis’ abdomen  Procedure performed on living women in Ancient China : Transforming Maternity Care
  4. 4. Suetonius 1506 Woodcut Lives of the Twelve Caesares : Transforming Maternity Care
  5. 5. Why is it Called “Caesarean”?  Named for the birth of Julius Caesar?  Unlikely because in ancient Rome the procedure was done only when the mother was dead or dying but Caesar’s mother, Aurelia, lived to hear of his Conquest of Britain. : Transforming Maternity Care
  6. 6. Oh, I see….  Possibly from the Latin “caedare”, meaning “to cut”  Roman Law stated that women dying in childbirth must be cut open to remove the infant.  Latin word “caesones” refers to children born by postmortem incision. : Transforming Maternity Care
  7. 7. Finally, we have a live one!  In 1500 Jacob Nufer, a Swiss pig gelder, performed a Cesarean on his ailing wife. She lived to be 77 years old, and birthed 5 more children vaginally, including a set of twins. : Transforming Maternity Care
  8. 8. But Still Gruesome….  Between 1787- 1876, not a single Parisian woman survived the Cesarean operation. : Transforming Maternity Care
  9. 9. Performing Abdominal Surgery in Street Clothes Thomas Spencer Wells, Diseases of the Ovaries, 1872 : Transforming Maternity Care
  10. 10. From Fatal to….....Less Fatal  Maternal mortality rates dropped in the mid nineteenth century  1846 William Morton- Diethyl Ether  Women less likely to die from shock  1860’s Josef Lister- Carbolic Acid  Antiseptics and the germ theory : Transforming Maternity Care
  11. 11. From Less Fatal…… To Safe  C/S rates increase because:  Post WWII, many new hospitals built  Surgical technique improved  Spinal Anesthesia developed  Penicillin purified 1940  Roman Catholic religious concerns : Transforming Maternity Care
  12. 12. From Safe……to Every Day  Continued rate increase far outpaces rise in birth rate  Convenience  Physicians can schedule around vacations, dinnertime  Women can schedule time off from work  Cutting loses (Better a section a 6pm than a delivery at 3 am) Culture  “Too Posh to Push” – Victoria Beckam  Vaginal Preservation Society  C.Y.A.  Malpractice suits  twins , breech, or VBACs are too risky : Transforming Maternity Care
  13. 13.  Technology in the Labor Suite Strongly Correlates with CS rates  Labor induction  r= 0.57 (P<.0001)  Fetal monitoring  Early Labor Admission  “Failure to progress” leads to CS  r= .62 (P <.0001) : Transforming Maternity Care
  14. 14.  Financial  Ob/gyn’s must do more deliveries to pay MI  C/S birth reimbursement is higher than vaginal : Transforming Maternity Care
  15. 15. So, where does that leave us Today?  WHO and USDHHS recommend no more than 15% of all births be C/S  Beyond 15%, risks begin to eclipse benefits  Yet 1/3 women in CA deliver via C/S : Transforming Maternity Care
  16. 16. For every 5% decrease in the national primary CS rate there will be:  Between 14-32 fewer maternal deaths  33,000 fewer NICU admissions  An savings of $750 million -$1.7 billion in healthcare costs. Plante 2006 : Transforming Maternity Care
  17. 17. Risks of CS to Mother  Blood Loss/Transfusion ≥ 1000 ml  Postoperative Infections  Subsequent Infertility  Subsequent increased risk: placenta previa, placenta accreta, placental abruption and hemorrhage  Injury to bowel, bladder, pelvic vasculature  Rehospitalization  Maternal Mortality  RR: 1.6- 2.8 : Transforming Maternity Care
  18. 18. Risks of CS to Fetus  Higher rates of respiratory distress  5% C/S  0.5% vaginal  Possible iatrogenic prematurity  Double risk of NICU admission  Double risk of unexplained stillbirth in subsequent pregnancy : Transforming Maternity Care
  19. 19. : Transforming Maternity Care
  20. 20. Objectives  Identify regional variations of Age Adjusted Low- Risk C/S rates in California  Simplify regions: Northern, Southern CA and LA County  Identify excess rates of C/S deliveries (Exclude Hospitals with less than 100 births per year)  Inform hospital leaders; lead quality change : Transforming Maternity Care
  21. 21. Low-Risk Primary Cesarean Section Defined:  Number of Cesarean Deliveries per 100 deliveries among women who have not previously had a Cesarean section (excludes abnormal presentation, preterm, fetal death, multiple gestation, and breech procedures) Primary C/S rates are age-adjusted. OSHPD Data 2006 : Transforming Maternity Care
  22. 22. Age-Adjusted Low-Risk Primary C/S Rates distributed to quintiles and applied to regions:  0-20%; (Quintile 1: 5-13)  20-40%; (Quintile 2: 14-15)  40-60%; (Quintile 3: 16.1-16.9)  60-80%; (Quintile 4: 17-19)  80-100%;(Quintile 5: 19+) Quintile ranges are per 100 births : Transforming Maternity Care
  23. 23. Top and Bottom two Quintiles (40%) of Age-adjusted Low-Risk Primary C/S Rates: Northern CA Hospitals with rates > 17 Hospitals with rates < 16 n = 32/124 (25%) n=74/124 (60%) : Transforming Maternity Care
  24. 24. Top and Bottom two Quintiles (40%) of Age-Adjusted Low-Risk Primary C/S Rates: LA County CA Hospitals with rates >17 Hospitals with rates < 16 n=44/60 (73%) n=12/60 (20%) : Transforming Maternity Care
  25. 25. Top and Bottom two Quintiles(40%) of Age-Adjusted Low Risk Primary C/S Rates: Southern CA Hospitals with rates >17 Hospitals with rates < 16 n=34/80 (43%) n=40/80 (50%) Hoag memorial Scripps La Jolla : Transforming Maternity Care
  26. 26. Public Health Implications of Cesarean on Demand Lauren Plante 2006 : Transforming Maternity Care
  27. 27. What are the total regional excess cases above California’s mean primary C/S rate (16 per 100 live births)? : Transforming Maternity Care
  28. 28. Excess Cases of Low-risk Primary Cesarean Births (age-adjusted) above the State mean of 16 per 100 births. By Hospital San Francisco Bay Area 2006 Total Excess C/S Cases= 349 (3%) Total low-risk non prior C/S= 11,043 (11%) Total Live Births= 97,000 Good Samaritan San Jose Hospitals with more than 200 Excess Cases are labeled : Transforming Maternity Care
  29. 29. Excess Cases of Low-risk Primary Cesarean Births (age-adjusted) above the State mean of 16 per 100 births. By Hospital, LA County 2006 Total Excess C/S Cases= 4368 (20%) Total low-risk non-prior C/S= 22,327 (20%) Total Live Births= 114,846 Valley Pres Cedars Sinai Hollywood Pres Garfield Citrus Memorial Huntington Park : Transforming Maternity Care
  30. 30. Excess Cases of Low-risk Primary Cesarean Births (age-adjusted) above the State mean of 16 per 100 births. By Hospital, Northern CA 2006 Total Excess C/S Cases= 1312 (5%) Total Non-Prior C/S= 23,745 (11%) Total Live Births= 212,919 Good Samaritan San Jose : Transforming Maternity Care Hospitals with more than 200 Excess Cases are labeled
  31. 31. Birth Costs (In thousands) 20000 18000 16000 14000 12000 10000 Vaginal Birth 8000 Cesarean Birth 6000 4000 2000 0 Physician Cost Hospital Cost Total Cost : Transforming Maternity Care
  32. 32. Financial Implications of California’s Excess Cases (Complications excluded)  Total excess cases above state mean:  17,677  Excess Healthcare Costs per Annum:  $ 93,422,945.00  Total excess cases above 15 (WHO Recommendation):  40,654  Excess Healthcare Costs per Annum:  $214,856,390.00 : Transforming Maternity Care
  33. 33. Conclusion:  Next Steps?  Questions/Comments?  What benchmark should we use?  Is Geomapping a useful tool for sharing data? : Transforming Maternity Care

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