A decade ago, Joyce K. Edmonds began to explore what has become a growing source of trepidation in the United States and around the globe. While Cesarean sections account for nearly one in three births in the United States each year, reams of evidence show that, all too often, the procedure is medically unnecessary.
Joyce Edmonds, photograph: Caitlin Cunningham
Edmonds, like most experts in maternal health, was familiar with the disproportionate number of C-sections (as the procedure is most commonly called) performed each year—and the dangers that they may pose. But as she surveyed her subject, she also discovered a curious gap in the research.
“There wasn’t a lot of scientific literature on the impact nurses have” on whether or when babies should be delivered vaginally or through a C-section, says Edmonds, an associate professor in the Connell School of Nursing.
She found the lack of information puzzling. C-sections, after all, are the most common major surgery performed in the United States, according to the federal Agency for Healthcare Research and Quality. Nurses, who frequently bring years of experience to the labor and delivery room, are key players in every stage of childbirth and yet their role in the decision-making process for C-sections is virtually unknown.
Nurses know that honing skills—such as coaching women on position changes and breathing and simply staying close to bedside during labor—leads to fewer C-sections.
“Nurses spend more time at the bedside than any other clinician, including doctors and midwives,” notes Edmonds. They monitor mother and infant’s vital signs, time contractions, coach mothers on breathing, and perform other essential roles. Nurses know that honing skills—such as coaching women on position changes and breathing, and simply staying close to bedside during labor—leads to fewer C-sections. Edmonds’s ultimate goal is to catalog these behaviors, which can be observed and quantified, then modeled by and for other nurses.
She is working on this with Neel Shah, M.D., an assistant professor of obstetrics and gynecology at Harvard Medical School, obstetrician at Beth Israel Deaconess Medical Center, and director of Delivery Decisions at Ariadne Labs, a joint venture of Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. The two are co-investigators in “Defining the Role of Nurses in Influencing the Likelihood of Getting a C-section,” a study that aims to develop a method of tracking the behaviors and practices of individual nurses to birth and delivery outcomes. The study is supported by a $120,000 grant from the Cambridge-based Rx Foundation—a non-profit that funds projects focused on improving health care quality and access.
A mother seeing her new born baby for the first time after delivery by Cesarean section. Photograph: ©Emilia Whitbread/Alamy Stock Photo
According to Shah, while lifesaving in some cases, two-thirds of C-sections are not only non-essential, they expose many women who could safely deliver babies vaginally to life-threatening complications such as hemorrhage, sepsis, or permanent injury to an organ (for instance, the bowel or bladder). “The majority of C-sections don’t need to happen,” he says. But better understanding of the decision-making process behind C-sections could lead to a better understanding of which patients would most benefit from the procedure.
At this point, such information is rarely captured in electronic health records (EHRs), the go-to source for scientists studying associations between clinical practices and patient outcomes. Were it available, Edmonds and Shah say, they could identify nurses whose patients have low rates of C-sections. Then, in a follow-up investigation, they could study these clinicians’ methods.
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In a C-section, a baby is delivered through incisions made in the mother’s abdomen and uterus. Some C-sections are medically necessary—when a fetus is very large, for example, or if it is in the breech (feet or buttocks first) position. An emergency C-section may be required if the fetus isn’t receiving adequate oxygen or is otherwise endangered.
But like any form of surgery, even the most routine C-sections carry risks. A large 2015 study by the Centers for Disease Control and Prevention (CDC) found that women who had a first C-section were significantly more likely to suffer potentially serious complications and require treatment in the intensive care unit.
C-SECTIONS AND RISK
Compared to a woman who delivers a baby vaginally, a woman who has a first C-section is:
3 TIMES more likely to need a blood transfusion
8 TIMES more likely to suffer a ruptured uterus
5.5 TIMES more likely to require an unplanned hysterectomy
6.5 TIMES more likely to end up in the intensive care unit
Source: National Center for Health Statistics
Moreover, once a woman has undergone a C-section, doctors frequently recommend that subsequent births be performed the same way, owing to a rare risk of uterine rupture in women with uterine scars who deliver vaginally. Shah’s research has also shown that women who have C-sections and later require hysterectomies have an increased risk for complications.
In 2015, the World Health Organization published a statement on C-section rates, noting that the procedure is necessary to protect maternal and infant lives in only about 10 percent of births within a population—higher rates confer no additional benefit. Yet the rate was more than three times as high—31.9 percent—in the United States in 2016, according to the CDC. The high rate isn’t due to consumer requests or preference; a tiny minority of pregnant women, no more than 2.5 percent and perhaps significantly fewer, ask their doctors to perform C-sections, according to the American College of Obstetricians and Gynecologists. Other oft-cited explanations, such as high rates of obesity in the US, don’t adequately explain the prevalence either, says Shah.
Economics, on the other hand, certainly appears to play a leading role. Studies indicate that C-section rates for low-risk pregnancies vary up to tenfold from one hospital to another. Obstetricians, Edmonds notes, are allowed considerable discretion in how to respond when a vaginal delivery proceeds slowly.
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Edmonds met Shah at a medical meeting in 2015. “I had been told by several people that I needed to connect with him—that there was a lot of similarity in our work,” recalls Edmonds. Shah has found working with Edmonds to be a natural fit. “Joyce is brilliant and relentless,” he says.
In 2017, the two led a study showing that the likelihood that a woman with a low-risk pregnancy undergoes a C-section varies nearly threefold depending on which nurse attends her delivery. To obtain data for the study, which was conducted at Massachusetts General Hospital and published in Journal of Obstetric, Gynecological & Neonatal Nursing (JOGNN), Edmonds worked with the hospital’s information technology department to create a system for linking nurses to births.
Shah was surprised to learn that C-section rates among nurses’ patients could vary so much. But Edmonds says the research simply quantifies what’s well known on labor floors. “Some nurses are better at facilitating vaginal delivery than others,” she said. Certain labor-floor nurses are especially skilled at coaching women to use birthing positions that ease the baby’s descent, for example. Or they’re better able to manage expectations about pain, helping a woman to endure long labor. Another key factor, says Edmonds, is “how a nurse communicates with the physician to allow the patient more time to labor.”
Knowing which of these skills and practices are associated with fewer C-sections could help reduce unnecessary use of the intervention. But Edmonds and Shah first need to replicate and expand the findings of their JOGNN paper to demonstrate that it’s possible to accurately identify nurses with low C-section rates. “To do that, we need data,” says Edmonds.
C-section rates for low-risk pregnancies vary up to tenfold from one hospital to another.
As it turns out, they have “hit a gold mine,” she says. A Seattle-based organization called the Obstetrics Clinical Outcomes Assessment Program (OB COAP) provided the researchers with three years’ worth of records linking every nurse who cared for a woman having a baby, and the method of delivery, at 10 hospitals in Washington State. (Similar data from Cedars-Sinai Medical Center in Los Angeles will be included in the study too.)
If this study, slated for completion this October, confirms that it is possible to identify nurses with low C-section rates, Edmonds hopes to use the new tool to pick out these skilled clinicians at several teaching hospitals, then observe and interview them. This data could form the basis of training programs for nurses aimed at reducing C-section rates. “Ultimately,” says Edmonds, “we want to create an evidence-based profile of the most effective practices of the labor-and-delivery nurse.” ▪