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Some Gains, But More Room for Improvement in NJ Maternal Care

Many Garden State birthing centers have more work to do to reduce cesarean sections and other potentially hazardous procedures

Pregnant woman
Credit: Twenty20

Maternal care is getting better in New Jersey, a new report shows, but Garden State birthing centers still have room for improvement when it comes to reducing the number of cesarean births and other potentially risky procedures.

Data released last week by the nonprofit watchdog Leapfrog Group shows that in 2017 three out of four New Jersey hospitals with labor and delivery practices reported C-section rates that were higher than the national target of less than 24 percent of live births. While sometimes medically necessary, the procedure carries risks of blood clots and pelvic pain for the mother, plus asthma and other chronic diseases in infants.

In addition, the state Department of Health launched its new maternal data center on Tuesday, with detailed statistics from 2016 that showed each facility’s C-section rates. Only eight of New Jersey’s 49 hospital birthing centers — or 16 percent — met the national C-section goal that year; on average, the hospitals performed the surgical procedure in nearly one in three deliveries.

For the DOH, the greater transparency is part of a larger push to work with hospitals and use data to drive better clinical outcomes. In April, the state shared the data with birthing centers, as well as evidence-based strategies to reduce surgical births. Leaders from most of the hospitals have also committed to work with the department to further reduce their use of C-sections, the department said.

‘Too many’ preventable C-sections

“Cesarean births are a major surgery that increases the likelihood of birth complications, such as maternal bleeding, infections and blood clots,” said New Jersey Health Commissioner Shereef Elnahal. “While these procedures can save lives, too many women in our state are experiencing preventable C-sections, which are putting them at unnecessary risk for injury or death.”

The new data also reflects a growing trend toward greater public disclosure. With the information on its website, the DOH hopes to educate and empower women, so they can fully understand the potential dangers of early elective births — which typically involve the surgery — and how it can impact their future pregnancies. The vast majority of mothers who have a C-section for their first child also have C-sections when delivering future babies. Women are urged to use the data as a starting point for a conversation with their provider.

Some labor specialists, like Dr. Payal Shah, the chief of obstetrics and gynecology at Holy Name Medical Center in Teaneck — one of the 11 New Jersey birthing centers with C-section rates below Leapfrog’s target — are already witnessing the benefit of this new transparency. Easy access to hospital data through Leapfrog, which created a user-friendly search system, and news coverage of its reports have led patients to arrive with informed questions about Holy Name’s maternity practices and outcomes.

“Patients in general are definitely much more educated about the choices they’re making for doctors, for hospitals,” Shah said. “People have done their homework before they come in.”

Infant mortality has declined in New Jersey and remains below the national average — although there is significant racial disparity in the rates — but maternal mortality has increased, exceeds national levels, and involves among the highest racial gaps in the United States. Recent state data shows that for each 100,000 live births in New Jersey, 12.8 white woman die and 46.5 black woman lose their lives within a year of the pregnancy.

Working on the racial disparity

Under Gov. Phil Murphy, Elnahal and other state officials have focused significant attention on the problem. The DOH has invested at least $4.7 million in training doulas, or nonmedical birth coaches, and community health workers to help women access prenatal care and to be able to have a birth that reflects their wishes, if clinically possible.

Lawmakers have also proposed several plans to improve outcomes and the state Department of Human Services, which runs Medicaid, has changed its payment rules to help reduce early elective deliveries.

“Every mother deserves an equal chance at having a healthy child,” said First Lady Tammy Murphy, who has led Nurture NJ, a multi-agency program to improve birth outcomes. “Our goal is to make New Jersey the safest place to give birth in the country.”

Leapfrog, founded in 2000, publishes an annual Hospital Survey, data from which served as the basis for the maternity report. Participation in their studies is voluntary but New Jersey has nearly universal participation, one of the highest rates of any state. (All Garden State facilities are expected to submit data for the next round, according to Leapfrog.)

In its review, Leapfrog found Garden State birthing centers have made real progress in some areas, including reducing the use of episiotomies — a surgical slit made in a woman’s birth canal to ease delivery — which can cause infection, delayed recovery, and bowel and bladder problems. Use of the practice declined from around 13 percent in 2016 to just over 10 percent two years later, the report found.

Decline in early elective deliveries

There was also a decline in early elective deliveries, often considered an unnecessary use of C-sections, from more than 3 percent in 2016 to less than 1 percent in 2018. In addition to the surgical risk to mothers, these early births can also put infants at risk, Leapfrog notes.

“We’ve seen that a focused approach of looking at the data, sharing best practices, and discussing each Cesarean section is leading to better performance,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute and a regional leader for Leapfrog.

In all, eight hospitals met Leapfrog’s metrics for the use of C-sections, early elective deliveries and episiotomies, five of which are in South Jersey. “We want to congratulate these eight hospitals for making the commitment to providing high quality care in their labor and delivery units,” Schwimmer said. “And we encourage other New Jersey hospitals to continue working to meet these important measures.”

The eight facilities are:

  • Cooper University Hospital, Camden;

  • Inspira Medical Center, Elmer;

  • Inspira Medical Center, Vineland;

  • Jefferson Washington Township Hospital, Washington Township;

  • RWJBarnabas Health Monmouth Medical Center, Long Branch;

  • Trinitas Regional Medical Center, Elizabeth;

  • University Hospital, Newark;

  • Virtua Voorhees Hospital, Voorhees.

When it came to C-sections alone, three other birthing centers also had rates below Leapfrog’s target: Capital Medical Center in Hopewell, Ocean Medical Center in Brick, and Holy Name.

Shah, at Holy Name, said the Teaneck hospital — which delivered around 1,200 babies last year and had an 18.8 percent C-section rate on Leapfrog’s latest report — has focused on creating a culture that supports women in their choices of delivery. At Holy Name, they also start with the goal that every patient should have a vaginal delivery, if possible, and provide women as much freedom of movement as possible during the birthing process, she said.

“You have to take the time to have these conversations with patients,” Shah said of discussions about birthing plans. “It’s all about communication.”

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