Proactive Management Linked to Higher C-Section Rates

Hospitals with the most proactive unit culture management had a higher risk of cesarean delivery, postpartum hemorrhage, blood transfusion, and prolonged hospital length of stay.

Having proactive management strategies that aim to tackle challenges before they occur is often a goal for hospitals, but when it comes to maternal health, such strategies may backfire.

That’s the finding of a new study showing that hospitals with the most proactive unit culture management had a higher risk of cesarean delivery, postpartum hemorrhage, blood transfusion, and prolonged hospital length of stay, independent of women’s health.

The study, from Harvard T.H. Chan School of Public Health and colleagues and published online in Obstetrics and Gynecology, is the first to link management of unit culture, nursing, and patient flow to maternal health outcomes. 

“It is hard to predict when women will go into labor, how long labor will take, and which women may require critical resources like the operating room or blood bank. The way managers address this uncertainty appears to be an independent risk factor for a woman getting a C-section,” senior author Neel Shah, MD, MPP, an obstetrician and Harvard Chan School researcher who leads the Delivery Decisions Initiative at Ariadne Labs, a joint center of Harvard Chan School and Brigham and Women’s Hospital, said in a statement.

The study included interviews with 118 nurse and physician managers at 53 diverse hospitals about three areas of management:

1. Unit culture management, including practices that facilitate communication and collaboration among staff
2. Nursing management, including practices that ensure appropriate nurse staffing levels
3. Patient flow management, including practices that adjust resources to accommodate surges in patient arrival

Hospitals were categorized as having either “reactive” management practices that address management problems as they occur or “proactive” management practices. The researchers then examined how these practices affected outcomes among a sample of 226,463 low-risk obstetric patients.

Among their findings:

• Patients who received care at the with the highest unit culture management score had a 30% higher relative risk of low-risk primary cesarean delivery than patients who received care at the hospital with the lowest unit culture management score.
• Patients who received care at the hospital with the highest nursing management score had a 47% higher relative risk of low-risk primary cesarean delivery than patients who received care at the hospital with the lowest nursing management score.
• Patients who received care at the hospital with the highest unit culture management score had a 313% higher relative risk of prolonged length of stay than patients who received care at the hospital with the lowest unit culture management score.
• Patients who received care at the hospital with the highest unit culture management score had a 157% higher relative risk of postpartum hemorrhage and an 87% higher relative risk of blood transfusion than patients who received care at the hospital with the lowest unit culture management score.

“Hospitals with higher cesarean delivery rates may have instituted more proactive management practices to lower their rate leading to a reverse causality effect, where cesarean delivery rates drive management practices rather than vice versa,” the authors write. “Further research into this counterintuitive finding should also investigate whether there is a relationship between management practices and management goals.”