Why Do Some Countries Do More C-Sections than Others?

PIERRE BARKER: In medicine, often we find ourselves in a situation where we’re trying to deliver exactly the right dose of medicine or the right type of procedure, based on what we understand from the evidence.

Caesarean sections is an interesting illustration of the way in which, across the world, the life-saving procedure of Caesarean sections is either not available enough — to women particularly in low-income countries — or it’s overused, particularly in middle-income countries and in high-income countries. And there are very few countries that seem to have got it just right.

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. You just heard from Pierre Barker. Pierre has global partnerships at the Institute for Healthcare Improvement. He has worked as a doctor in South Africa, the United Kingdom, and the United States, so he has a really interesting perspective on what health care looks like in different countries.

But for now, we’re coming back to this problem where there’s an imbalance in C-section rates around the world. Pierre’s organization, IHI, is trying to solve the problem by using something called “quality improvement.” Now, advances in science mean that we have ways to treat very serious medical conditions. But the question remains — Why are people not getting the health care they need? Why are so many lives being lost?

And quality improvement is a strategy to improve health care that addresses this. It includes how people experience the care they receive, but it also includes the health of the broader population, like strategies to keep people healthy.

And there’s another element, which is — How much does it cost to provide that care, and can people afford that? And Pierre will talk more about this later, but for now, let’s get back to this problem. Why do C-section rates vary so much across the globe?

PIERRE BARKER: So it’s really interesting if you look across the globe at who gets Caesarean sections and who doesn’t. It’s easy to understand that if you don’t have the doctors and nurses, as is the case in poor countries, or if you don’t have operating rooms, that women who need it — and particularly women who are in the rural areas and can’t get to a place of care — that they just will not get it, despite running into problems with labor or their babies being in trouble, which are the main two reasons for people getting Caesarean sections.

But then if you look across the different economies, you’ll see that the real epidemic in Caesarean section is happening in the middle-income countries. And so if you look at countries like China and Iran, Egypt — and particularly in the countries of Latin America — you’ll see Caesarean section rates very, very high.

SHANOOR SEERVAI: So what’s the recommended number of rates of C-sections? You were saying 85 percent?

PIERRE BARKER: Well, actually what’s recommended is that every mother should be offered the opportunity to deliver her baby in exactly the way that’s right for that mother and baby.

So if you look at this at a population level, the WHO is saying that there’s no real advantage if the Caesarean section rate is above 20 percent. In other words, the mother won’t receive benefit, and the baby won’t receive benefit if, on average, the Caesarean section rate is above 20 percent.

On the other hand, we know that if you are not able to deliver at a population level a Caesarean section rate of above 10 percent, then there will be many women who need Caesarean sections who are not getting it.

So there’s a sweet spot of somewhere between 10 and 20 percent. And if you look across the globe, there are only about — I don’t know — five, six, seven countries that actually deliver to their populations in that sweet spot. And most of those are in Scandinavia.

SHANOOR SEERVAI: But what’s going on in the countries that are below the sweet spot? Which are the countries that have a C-section rate that’s below 10 percent, where, as you say, there are probably mothers who need a Caesarean section but can’t get one?

PIERRE BARKER: So those are mostly in the low-income countries. So you’re looking at countries like India and some of the sub-Saharan countries that we’ve worked in, like Malawi. And these are countries that rarely have low numbers of health workers who can do the procedure — either doctors or nurses — and have hospitals and clinics that are not equipped to do Caesarean sections.

So it’s really a resource problem. But it’s not as simple as that. Some of the women who should be getting Caesarean sections don’t get them because of all sorts of complex behavioral issues. And we found that this issue of behavioral issues is something that is quite a big aspect of why women get Caesarean sections or don’t get them.

SHANOOR SEERVAI: Okay, and before we get into talking about how you’re actually trying to address this problem, just for our listeners here in the United States, what’s the C-section rate here?

PIERRE BARKER: In the U.S., it’s somewhere between 33 and 35 percent. So you can see it’s quite well above the rate that you might expect, compared to say, for instance, Sweden which has a rate of about 15 to 17 percent.

If I were to ask what are the top three causes of high rates of Caesarean sections, as I often do when I’m talking about this, people will respond in the United States. They’ll say, “Well, it’s because women are asking for Caesarean sections, or because doctors are fearful of litigation if everything doesn’t go right with a natural delivery.”

But when you look into the realities of this — in fact, the great majority of women enter early pregnancy hoping that they’re going to have a natural delivery. The amount of litigation that is directed at obstetrics is, in fact, quantifiable, but it’s very small in terms of the decision-making.

SHANOOR SEERVAI: So the reason that people believe this is a problem is actually not the real reason?

PIERRE BARKER: Yes, the real reason is more complex. So the real reason is because we have — and certainly in the United States — that we have turned something that is a fairly physiological and normal event which benefits from the intervention of Caesarean section when needed.

We’ve turned this into a highly medicalized event. And the more you medicalize the labor while it’s happening, the greater the chances are that you’ll end up having a Caesarean section.

Also there’s a sense that a Caesarean section is just an easy and safe thing to do. And if there’s any doubt, you might as well just do it.

And this really doesn’t take into account all the downstream consequences, all the consequences that happen after the baby is born, particularly in terms of the difficultly in bonding that often happens — the difficulty in establishing breastfeeding — as well as some of the medical complications of Caesarean section.

So it’s not something to be taken lightly, and it’s not a question of whether it’s a good or a bad thing. Again, it comes down to what’s the right way of delivering a baby for a particular mother and baby?

SHANOOR SEERVAI: That makes sense. And now that we have an idea of what the problem is, let’s talk about IHI’s and your approach to finding a solution, and where quality improvement really comes in.

PIERRE BARKER: Yes, so as you mentioned earlier, the purpose of quality improvement, really, is to close the gap between what we should be doing based on the medical evidence, and what we’re actually doing.

And people often ask me, “So what sits at the core of this?” And I say it’s a disciplined way to take ideas for change and to see if they work. It’s a very adaptable method that takes account of the local environment. And we also respect the fact that the solutions to why we’re not delivering care in the way that it should be delivered — the solutions often reside with the people right at the front line who are taking care of mothers and babies every day.

So there are four ways in which we think that we need to approach change in a system. The first is to recognize that change is hard, that people like doing what they’re doing. We’re wired to do what we’ve always done. And we’re also quite resistant to change. So understanding the psychology of change is really important. And this is where we have to really engage leaders who have to create an environment where change is possible.

The second is to get people to understand how their systems work. We help them with system thinking, and we get them to analyze their own situations. And that lays open the opportunity for them to come up with ideas to solve the problems that, in this case, to try to decrease the rates of Caesarean section.

It’s very important for them to also track what they’re doing, because the tendency is just to try to do some improvement without really tracking to see whether the ideas that you’re applying are working. So we really encourage people to measure what they’re doing.

And finally, there’s a real need to take a bottom-up approach, to learn what works and what doesn’t work, and to resist the temptation as leaders and managers just to come in with solutions and expect people to follow them, even if they have not been tested. So that’s the basic idea of how we go about trying to change the performance of a system.

SHANOOR SEERVAI: And when you’re trying to change systems when it comes to C-sections, you know on the one hand in some places, the rates are too high. On the other hand, it’s too low in other places. So how do you use this framework to change different kinds of systems?

PIERRE BARKER: Well, if you look at the case of Brazil — so Brazil has the unenviable position of having the world’s highest rates of Caesarean section. So this is a good place to go and test out some of these ideas and see whether we can make a difference.

The start of this work actually — and this is often how we like to start — was just in one hospital in Sao Paulo province, where a partner of IHI’s became familiar with the method and decided to try to do something about the almost absence of natural delivery in that obstetric hospital in Brazil.

And this is Paulo Borem, who’s now leading a major initiative for us in Brazil. And what he did was he said, “Let’s start with getting people to agree to what the right thing to do is. Let’s get a declaration from the hospital leaders and from the insurers and from the doctors and from the nurses that the current situation is just untenable, and it’s not right. It’s not acceptable that 90-plus percent of the women in the hospital are delivering by C-section.”

And just getting that agreement — that everyone agrees that something needs to be done, and that we’re going to do something about it is a fundamentally important starting point. And they started looking at some of the evidence-based practices that we know will lead to a decrease in the rate of Caesarean section, like de-medicalizing the experience of labor while keeping a woman safe.

So if you have a labor room, which is what I’ve seen in some hospitals in Brazil, which can in a flash be turned into an operating room and is full of high-tech equipment constantly monitoring the mother, constantly monitoring the fetus. You create an atmosphere of fear and expectation that something is going to go wrong.

Whereas they’ve now created rooms which are some distance away from the operating theatre, which are quiet, which are comfortable, which create an ambience of peace and support for mothers, paying particular attention to pain control, because fear of pain is way and above any other reason given by Brazilian women as the reason that they don’t want to have a natural delivery.

Secondly, in Brazil, most of these deliveries, particularly in the private system, are done by doctors. Midwives are nowhere to be seen. So incorporating midwives into the team, allowing midwives to actually deliver uncomplicated deliveries — these are some of the factors.

And then, remarkably, many of the obstetricians actually were uncomfortable about delivering naturally. They had never delivered a baby naturally in their professional life. And so through the facilities of the Einstein Hospital in Sao Paulo, we managed to retrain these doctors using simulation about how to deliver babies naturally.

Then we gave them data systems where they could actually track whether or not their interventions were working. So that’s how we approached it. The hospital themselves set themselves a target of delivering all babies — sorry — delivering 40 percent of all the babies by the natural route, starting from almost zero. And over the next nine months or so, they were able to reach their target of around 40 percent.

SHANOOR SEERVAI: What’s striking to me — the things that you have described changing, which is getting doctors, hospitals, insurers to agree that this is a good thing, involving midwives, making sure that all deliveries are not happening in operating theatres but are just in comfortable, quiet spaces — none of this sounds as if it’s very expensive or as if it requires the cutting-edge medical technology, but they are really important ways of impacting the way people behave, and then impacting the way that women have their babies.

PIERRE BARKER: Yes. I mean, the work is not done. There is a lot of resistance to this, as you can imagine, from the solo private practitioners because their whole style of working is that they are working on their own, and they expect a woman to follow their advice, which is mostly that they should have a Caesarean section.

It’s very interesting, looking at the data coming out of Brazil, is that even in the private sector, only about a third of mothers in early pregnancy say that they want a Caesarean section. By the time they are about to go into labor, about 65 percent of them are now saying they want a Caesarean section. And by the time they actually deliver their baby, 85 to 90 percent of them will have had a Caesarean section.

So there’s something happening along the way, where mothers are being persuaded, from their own instincts initially to want to have a natural delivery, towards having a Caesarean section. And it’s that dynamic that we really have to get to, in order to get us from our current rate of 40 percent — which is still very low — because we know that 85 to 90 percent of these low-risk women should be having natural deliveries.

SHANOOR SEERVAI: Imagining what it’s like to be a woman, a pregnant woman in Brazil, if I’m going in to see my doctor, and I’m constantly being told, “You should have a C-section. You should have a C-section.” At some point the idea that we’ve all grown up with — doctors are figures of authority. We should listen to what they have to say. That’s what’s going on. And how do you change that?

PIERRE BARKER: Well, we have to work, you know, on multiple levels. This is not going to be solved easily. We have been working with the doctors, but I think what we realize that we haven’t really been working enough with the women. And now that we understand that women are having their minds changed during the prenatal period, during care and pregnancy, that’s a really great opportunity to start working with women.

And there are some interventions that we are now starting to use, one of which is called centering, which is where women go through their pregnancy as a group, as a cohort together, where they can discuss issues like the way they want to deliver their baby. And we can also start using some methods like simulation, where we actually help to prepare them and equip them with good questions and good answers when they’re going through these discussions with their doctors.

SHANOOR SEERVAI: Well, what if we now move to the other side of the world, India, and talk about the situation in which the balance is tipped in the other direction, where there just aren’t enough women getting C-sections when they need them. What have you learned from your work there?

PIERRE BARKER: So it’s been a very interesting and challenging and very different kind of problem, as you can imagine. So what we’re trying to do there is take the very few resources that are available and help come up with solutions to reorganize those resources in such a way that they’re available to the women who really need them.

So one of the very simple things that we did was to observe that there wasn’t a simple roster for doctors to be available to do Caesarean sections at different times of day and night. And so they came up with a roster where doctors would agree to be available.

So these are simple interventions that the teams themselves came up with that we put into practice in order to see whether they worked. And, in fact, they did work. And what I was talking about at the beginning is the social dimension and some of the behavioral aspects that, similar to Brazil, are in fact some of the biggest barriers.

So this idea of financial incentives that are applied in ways that are really not helpful will drive behaviors that will lead to a woman inappropriately being given stimulants to try to hurry along labors when they become obstructed. And this is very dangerous, both for the mother and can cause brain damage from lack of oxygen for the baby.

In the worst cases that we’ve heard about of mothers actually being diverted on the route by ambulance — being diverted away from a hospital where they know they’re going to get a Caesarean section because the accomplices want them to have a natural delivery so they can get paid.

These are assistants who will accompany a mother from her home to the place of delivery. They get paid for bringing the mothers to the place of delivery, and then they get paid for supporting the delivery of a baby. And obviously if the mother then goes to an operating room, they won’t be credited with having helped that baby get delivered, and they won’t get paid.

SHANOOR SEERVAI: Tell me about how you are working on altering the system of financial incentives — especially in a country that is resource-poor — people need jobs. People are probably dependent on these financial incentives.

PIERRE BARKER: Yes, that’s a long-term project. Right now all we can do is really create systems that can circumvent that. So one of the systems that has been put into place is to improve the communication between primary care facilities where these mothers are first seen, to district hospitals, where they get their Caesarean sections.

And these teams have formed WhatsApp groups, so they’re all connected to WhatsApp, and it’s become a primary way of alerting the hospital ahead that there’s a mother on the way, of communicating the information about the mother. And so when the mother doesn’t turn up at the district hospital, the team that is receiving the mother or should be receiving the mother can start calling around. And they know now that they’re being tracked, and it makes it harder to divert and hide mothers as they transit.

SHANOOR SEERVAI: It sounds like it’s really hard work, but a slow and steady process is what’s required to change behaviors that are so entrenched.

PIERRE BARKER: Yes, that’s true. So there’s 10 hospitals that are working together in a collaborative, where they share knowledge and solutions in their challenges. And we can see that those 10 hospitals have gone from an average rate of about 4 percent Caesarean sections to a rate now of about 10 percent. So it’s definitely working, in the same way as we’re driving up natural deliveries in Brazil and seeing results, we’re seeing results in India, where we’re driving up Caesarean sections.

SHANOOR SEERVAI: And then finally if we look at the third case — countries like the United States. Could you talk about work you’re doing here?

PIERRE BARKER: Yes, we’ve done work in Louisiana, working with the hospitals across the state there, where we’ve really focused on the one issue that often leads to inappropriate Caesarean section. That’s giving an induction — in other words, starting to stimulate labor — before the baby is ready or before the mother is ready.

So there is a recommendation in the United States that you should not start stimulating labor before 39 weeks of gestation. And just that simple intervention, where you carefully track the gestational age of a mother, and then you bring in a monitoring system that makes it very difficult to start stimulating labor before 39 weeks. That simple intervention alone has led to a significant decrease in the number of Caesarean sections in that state.

SHANOOR SEERVAI: And again, here we’re seeing an example where it’s not a matter that there aren’t resources, or it’s not a matter that the recommendation didn’t exist, that a woman should not — that there should not be an elective C-section before 39 weeks. But it’s really about getting people to change the way they’re behaving.

PIERRE BARKER: Exactly. The stimulation of labor before 39 weeks — that rule has existed. And so the question is, Why weren’t people following it? And the quality improvement method really helps people to understand the underlying reasons for the rule.

It helps them to then start working on processes to ensure that the rule is followed. And it also gives them the data that shows that they’re doing it or not doing it. And it’s a very powerful combination when you adhere to that method. That profoundly changes the way in which people are practicing.

SHANOOR SEERVAI: If a woman had a choice of being able to deliver a baby anywhere in the world, where would you recommend that she go?

PIERRE BARKER: That’s a very difficult question. I’m very impressed with the way in which childbirth is approached in the United Kingdom. Now they have a Caesarean section rate, I think, of around 25 percent, which is probably a little high, but there’s a very strong midwife-led service there.

I think the NHS is a very safe place to have a baby. But on the other hand, I’ve just returned from a trip to Sweden, where again, midwives really lead the obstetric services, and babies get Caesarean sections clearly for good reason, when they need it.

And of the two countries, the newborn mortality rate in Sweden is lower than the U.K. So somewhere between those two countries.

SHANOOR SEERVAI: All right. Well, thank you so much for joining me on the show today, Pierre. This has been really interesting.

PIERRE BARKER: It’s been my pleasure. Thank you.