An Oklahoma hospital has a new system to reduce C-sections: It starts with a simple whiteboard.

"Survival is the floor of what women deserve during childbirth, but when we’re defining a better system we should be aiming for the ceiling."

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Saint Francis in Tulsa is one of only four hospital in the country to pilot a program aiming to reduce C-section rates. KASSIE McCLUNG/The Frontier

Forgotten Mothers: This story is part of an ongoing series by The Frontier to examine and investigate maternal health in Oklahoma.

As Trisha Short walked down a hall on the labor and delivery floor of Saint Francis Hospital in Tulsa on Tuesday, she paused to reflect on the already busy week.

“Yesterday we had 27 deliveries,” said Short, the perinatal safety nurse for the hospital.

Over the last year, hospital leaders have revised how babies are delivered at the facility. There’s more communication between staff and mothers now. Families seem happier with their birth experiences. And most of all, there’s been a change in the number of cesarean sections.

“We are already starting to see a decline in our primary C-section rates, so that’s exciting,” Short said.

Tuesday marked one year since Saint Francis started the new approach. The hospital has been putting to test a “Team Birth” initiative developed by Ariadne Labs, “a joint health system innovation center” of Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health in Boston.

Saint Francis is one of only four hospitals in the country to take part in the pilot program. The other hospitals are South Shore Hospital in Massachusetts, and Overlake Hospital and Evergreen Hospital in Washington.

The program’s plan seems simple: Communicate.

A key way of measuring the program’s success is by looking at the rate of C-sections. Dr. Neel Shah is an obstetrician and directs the Delivery Decisions Initiative at Ariadne Labs. He said he’s hoping the number of unnecessary C-sections goes down.

Though C-sections can be life-savings surgeries for some high-risk women and for uncommon conditions, they increase the risk of life-threatening complications during and after delivery, such as infection, hemorrhage and hysterectomy. The procedure can also raise the risk of death.

“We know that C-sections can be life-saving surgeries … but at the same time, sometimes especially when we look out across the country and look out across the world, places that do too few C-section rates or in many cases places that do too many C-sections, that’s a sign that they’re not managing labor or supporting women in labor as well as they could,” Shah said. 

In fiscal year 2018, Oklahoma’s Medicaid program, SoonerCare, paid for almost 29,000 deliveries — just over a quarter of which were performed via C-section, according to Oklahoma Health Care Authority data (that doesn’t capture all deliveries in Oklahoma).

Meanwhile, the World Health Organization recommends C-sections make up no more than 15% of all births, and a more recent study found no more than 19% of births should be by C-section. 

Shah said in most settings, 90 percent of adverse outcomes of delivery — including severe injuries and death — are rooted in challenges around communication and teamwork.

“So when you read the national headlines about maternal mortality a lot of the explanations about the root causes, they get attributed to diseases or medical conditions, like hemorrhage,” Shah said. “But you know, that doesn’t necessarily explain why the hemorrhage is leading to really bad outcomes for people.”

Oklahoma hospitals in 2017 reported 830 women experienced life-threatening complications related to pregnancy or childbirth. Hospitals recorded 800 cases in 2016. On average, one woman dies each month in Oklahoma from complications related to pregnancy or childbirth.

Trisha Short, perinatal safety nurse with Saint Francis Hospital, gives an example of what a planning board might look like. KASSIE McCLUNG/The Frontier

Ariadne Labs’ program intends to change the whole delivery process. First, the woman isn’t admitted to the hospital until she is in active labor. After admission, women can find a large, white erase board hanging on a wall in each room that helps direct the birth plan. Nurses give mothers a print-out that encourages them to have a conversation with their team about which delivery option might be best for them, such as assisted vaginal delivery or C-section. 

The planning board displays the names of everyone on the “team,” such as the mother, nurse and doctor, and lists the mother’s preferences — such as if she wants the baby’s father to cut the cord and whether she wants immediate skin-to-skin contact.

Another part of the board lists the care plan for the mother and baby, including giving the mother an epidural. The bottom section shows what the next step is and where the mother is in the delivery process.

“It turns out in 2019, putting a whiteboard in a labor and delivery room is an innovation,” Shah said. “There’s like no technology, there’s no AI involved, but the idea of structuring how the team talks it turns out is a big innovation.”

The goal is to improve communication to get mothers, doctors and nurses working as a team during delivery, even in cases in which they’re strangers.

“You can’t predict which doctor is going to be on call when any one woman goes into labor,” Shah said. “You can’t predict which nurse they’re going to get assigned. And even though each person is an expert, for every woman and every time, they don’t get a chance to have a dry run as a team.

“You’re just doing it at one of the most critical moments of our entire lives.”

The team also does occasional “huddles.”

“So the huddles are every time that something significant is happening,” Short said. “and that can be from the patient’s perspective, the nurse’s perspective or the physician’s perspective, but in those moments the three of us will come together as a team to discuss the current concerns and the options.”

Short, who helped lead the program’s implementation, said the hospital doesn’t have data on the project yet, but as the pilot programs come to a close at the end of the year, she expects to see more results. The reduction she has seen in the number of C-sections at the hospital is promising, she said. 

“This is the way that we will practice moving forward in the care that we provide. It will not end once the study’s over,” Short said. “This has transformed our culture and the care that we deliver here in a very positive way.”

Shah said he hopes to expand the project to other hospitals across the country and world. 

“Survival is the floor of what women deserve during childbirth, but when we’re defining a better system we should be aiming for the ceiling, which is care that’s not just safe but also supportive and empowering,” he said. 

Continued reading: 

A Frontier Investigation: Forgotten Mothers

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Kassie McClung

Staff writer

Kassie McClung joined The Frontier in May 2016. She reports on health, criminal justice and other state issues. Kassie holds a bachelors degree in multimedia journalism from Oklahoma State University. She likes dogs, maps and data. She can be reached at Kassie@readfrontier.com or 918-935-1044. Follow her on Twitter @KassieMcClung.
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