SAFELY, EFFECTIVELY REDUCING C-SECTION RATES Sutter Health | Sacramento, Calif. CASE STUDY Overview Founded in 1921, Sutter Health is a not-for-profit inte- grated health delivery system that operates 23 acute care hospitals and over 200 clinics in Northern Cali- fornia, with engagement in 30,000 births each year. In 1999, Sutter Health established its first pregnancy and delivery quality improvement program to create better outcomes for mothers and babies. Reducing the number of unnecessary first birth C-section rates was a key goal. It is estimated that nationally, about 26% of healthy women with low-risk pregnancies still undergo C-sections despite the potential risks to mothers and babies. Over the next few years, Sutter Health concentrated on implementing its "community of improvement" approach across its entire system. The health system formed a community improvement committee and standardized processes to reduce variation and track A continuous care approach opened the door wider for progress. different perspectives to collaborate and ensure a safe delivery. It also placed greater emphasis on bringing Sutter believes birthing is a natural process and not every participant in the birthing process into the same a medical intervention. They recommend admitting a "mindset," which contributed to improved outcomes. mom only when in active labor to reduce intervention, which reduces the likelihood of a C-section. Once ad- Specifically, in the first two and a half years of the mitted, each patient receives continuous labor support program, C-section rates declined from 25% to 18% from her Sutter birthing team. in Sutter's Alta Bates Summit Medical Center. The medical center has the largest delivery service in the From the outset, Sutter Health focused on estab- Oakland/Berkeley area. lishing a culture of teamwork and creating specific expectations for each position on a birthing team. According to Stephen Lockhart, M.D., Ph.D., founding The birth team consists of physicians, nurses, mid- director emeritus, Sutter Health Institute for Advancing wives and volunteer doulas, who are available free Health Equity, this early success served as the impetus of charge to support any nonmedical needs of an for the entire system to continually improve its work in expectant mother during labor and delivery. Water reducing unnecessary C-section rates. It also increased births also are an option. Each team member pro- the level of collaboration and buy-in among key special- vides encouragement and support throughout labor ists, including Sutter Health's obstetricians, gynecolo- and delivery. gists, anesthesiologists and others. ©2021 American Hospital Association | July 2021 Page 1 | www.aha.org Impact Future Goals Sutter Health's system-wide focus on improving the preg- Sutter Health leaders say the vast diversity of their nancy and delivery experience also boosted outcomes patient population offers a great opportunity to focus with regard to maternal morbidity, postpartum recovery on health equity as an overall component of quality. and patient satisfaction. During the same time period: Despite California's overall success in achieving declin- • S utter Health experienced a decline in patients being ing maternal mortality rates - which bucks national admitted in very early labor (less than three centime- trends - Sutter Health care teams note that racial and ters dilated) from 40% to 29%. This has resulted in ethnic differences appear to play a role in the decision less need for oxytocin, which in turn has led to fewer whether to choose a C- section birth. C-sections. Lockhart said this may indicate the existence of uncon- • E pisiotomies fell from 25% to 10%. With the conse- scious bias and that Sutter Health will look at incorpo- quent decrease in third and fourth degree lacerations, rating unconscious bias training and obstetrical coali- patient satisfaction went up. Currently, Sutter Health's tion training as part of the emphasis on diversity and episiotomy rate is below 3%, which is lower than the inclusion within its workforce. California average. Additionally, the health system intends to take a closer • S utter Health was able to create a more positive look at the factors surrounding preterm births so it can overall culture, one that acknowledged the vital role of connect expectant mothers with better prenatal care nurse midwives and their contributions to the birthing that addresses social determinants of health. team. Said Lockhart, "bringing [physicians, nurses, and all team members] into the same mindset made a "Those are some areas that we're really going to be huge difference." focusing on," summed up Lockhart. "A hallmark of our health care system is how we treat our mothers and Lessons Learned babies and the outcomes they experience. So we're very, very excited about continuing this work, and really Sutter Health leaders have learned that positive learning from others as well." energy and results tend to bring more of the same, producing better outcomes and results for patients and higher levels of professional satisfaction for Contact clinicians. They have cultivated great receptivity among their faculty to continual improvement. Stephen Lockhart, M.D., Ph.D. Founding Director Emeritus, Sutter Health Institute for An ancillary benefit of its quality improvement work has Advancing Health Equity been a significant decrease in surgical claims, mitigat- healthequity@sutterhealth.org ing the impact of the largest single area of lawsuits in health care. Sutter Health also has absorbed the importance of speaking with one voice, i.e., having leaders who will clearly set out goals and processes and expect them to be abided by. ©2021 American Hospital Association | July 2021 Page 2 | www.aha.org