Markham Stouffville Hospital

Upsetting the Apple Cart in a City in Southern Ontario: Changing the Status Quo Hierarchy and Higher Cesarean Rates

By Carol Cameron, RM, MA
(From: Birth Models that Nurture Cooperation between Professionals: Pizza and Other Keys to Disarmament. In Birth Models on the Edge: Finding Solutions to Global Controversies.
Ruiter, P. James A., and Cameron, Carol; Betty-Anne Daviss and Robbie Davis-Floyd, Eds. Berkeley and London: University of California Press. Forthcoming 2016).

The Fastest Growing Region in Ontario

MSH is also growing—in 2014 it began preparing to welcome 4,000 babies each year.“Markham Stouffville Hospital (MSH) is a community-based hospital located in York Region, the fastest growing region in Ontario, Canada, reporting a 22% increase in population size between 2001 and 2006. With a catchment area of over 300,000 people, MSH continues to experience a steady increase in the number of births each year. Of Markham residents in need of inpatient obstetrical care, over 40% visit MSH to receive their care. In 2011/12, the hospital welcomed 3,165 babies, an increase of 10.5% from 2004/05. As the community continues to grow, MSH is also growing—in 2014 it began preparing to welcome 4,000 babies each year.
A Level 2 hospital, MSH has a neonatal ICU allowing for management of gestation above 32 weeks. Since 2007, it has participated in the MOREOB (Managing Obstetrical Risk Efficiently) Program. Over the span of experience with the Program, the team at MSH grew from focusing not only on the clinical areas of risk identified in the program but in determining and tackling unit-specific needs and goals as a collaborative effort. At MSH, maternity care providers, obstetricians, family physicians, midwives and nurses now function as a well-integrated multidisciplinary team and have learned to collaborate. Providers meet regularly and jointly develop clinical guidelines and policies that reflect the spectrum of the various scopes of practice. The following is the story of how this teamwork and cooperation came about.

Cesarean Reduction Strategies Task Force

MSH experienced a rise in C-sections from 25% in 2005 to 29.6% in 2010, which is similar to the C-section rates in other hospitals in the Greater Toronto Area (GTA), but higher than the Canadian average. The induction rate increased from 16% in 2002/03 to 24% in 2009/10, and the Vaginal Birth after C-section (VBAC) rate significantly decreased over several years. For example, only 15% of women with a previous C-section attempted VBAC in 2010; of those, 77% successfully delivered vaginally.
A long-term goal of reducing C-section rates at MSH by 5%. In 2010, the MOREOB Core Team created a specific Cesarean Reduction Strategies Task Force. The role of the task force was to examine the reasons for these trends and to identify, implement and evaluate a range of evidence-based interventions, with a long-term goal of reducing C-section rates at MSH by 5%.
The task force brought together an interdisciplinary team of maternity care providers including midwives, nurses, obstetricians, anesthesiologists, pediatricians, and administrators.
The team started with stratifying data by multiple variables and decided to focus on induction and VBAC, as these were the two key areas identified for improvement. After a review of the literature on intervention strategies, the task force designed a specific plan to decrease these interventions and reduce the C-section (CS) rate. The interventions fell into three main categories: those aimed at pregnant women planning to deliver at MSH, those aimed at MSH providers, and those that would affect hospital policies.
Interventions targeting pregnant women included meetings with local prenatal educators to ensure consistency of information between educators and providers, revision of all patient education material to ensure that the descriptions of cesarean birth, VBAC, induction of labour and supportive care in labour in those materials reflected best evidence. Based on the principals of informed choice and group learning, a session for all women with a history of previous CS was established and led by the midwives. The Options for Birth Following Cesarean Birth sessions are an opportunity for women and their partners to discuss the reasons for their CS and to explore options for subsequent births. The session facilitator together with women who attend discuss the benefits and risks of both elective repeat CS and VBAC and use a patient decision making tool that assists women to fully explore their own specific risks and values. Session surveys demonstrate a high rate of satisfaction with the sessions among participants.

Session surveys demonstrate a high rate of satisfaction with the sessions among participants.

Supportive care in labour practices is a focused intervention where staff has been provided with education and tools to enhance one-to-one care for women in labour. Newly cross-trained perinatal nurses attend supportive care sessions with midwives, auscultation practices are encouraged (in order to minimize the use of the electronic fetal monitor), and an area for the nurse/midwife to sit comfortably in the room is provided. Bringing everything needed into the room, such as supplies etc., enabled the caregivers to remain in the room with the labouring woman. We provided comfortable seating, tools for documentation, and Vocera (a communication device), which were integrated into the room design.
Interventions aimed at practitioners began with rounds and data collection. We decided to communicate individual and provider group cesarean birth rates, VBAC rates, and induction rates. At the start of this process, the Chief of Obstetrics provided each physician and midwife a copy of their own personal rate along with their peer group’s rate; these results were blinded. After two cycles of releasing quarterly rates, the results were un-blinded at the request of all caregivers, and became known to all individuals in the peer group. These individual rates, overall unit rates and ‘work on reduction’ strategies are now a part of each department and division meeting. Overall hospital rates for CS, VBAC and induction are posted by management on the unit in a place visible to the public. Stories describing our CS reduction initiative, birth options sessions and overall rates have appeared several times in the local newspapers. Our experience is now growing as the ‘go-to’ place for other hospitals looking to reduce their CS and induction rates. Often a staff member will come back from an education event saying that other members pointed out that they knew of the reputation Markham Stouffville has around lowering CS rates.
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A Model for Change

In 2011 we partnered with the University of Ottawa and McMaster University and were successful in receiving a grant from the Canadian Institute of Health Research to study the effects of the initiative and the influences of it on our community of providers and patients. Currently the Queensway Carleton Hospital in eastern Ontario is replicating components of our initiative and the transferability of the project. We believe that we are a ‘model for change,’ yet realize that the ability to approach this type of change requires a cohesive group ‘living and breathing’ the MOREOB philosophy of collaborative, respectful and non-hierarchal team-based care.
All policies related to care of women in labour, VBAC, and induction of labour were reviewed and revised by our Patient Quality Committee working closely with the task force members. One of the discoveries we made during our data review was the number of non-medically indicated inductions that were specifically listed as ‘post-dates’ that were occurring. Our focus on the policy and process around this issue saw this rate fall to 1% for 2011/12. Furthermore, our overall induction of labour rate decreased from 26% to 12% over the intervention period. The task force together with management and professional practice rolled out the policy changes as a package and at varying times. It is difficult to know which may have had the most impact or whether the entire group of interventions working together achieved our results. We believe it will be possible to replicate results in other units by using our strategy of stratifying the data, targeting the leading contributors to the CS rate and using best evidence to guide and sustain practice.
At MSH our journey to reduce our CS rate began in April 2010. At that time (2009/10) the CS rate was 29.6. For 2010/11 this rate fell to 26.3%, for 2011/12 the rate was 26%, for 12/13 the rate was 25.8% and most recently in 13/14 our overall CS rate was 23.7%! While only 15% of women attempted VBAC in 2009-2010, this rate has also steadily risen and we saw 33.6% of women in 12/14 attempt VBAC, and about 80% of those having vaginal births. At MSH we surpassed our original goal of reducing the CS rate to 25%.
5.9% reduction in C-sectionsToday we all continue to work daily on improving care for women and holding each other accountable for high quality evidence-based practice. Our rates and indicators are tracked and reported monthly. Should the induction and CS rates fall above our goal two months in a row, the team strategizes what counter- measures can be adopted and put in place to return to goal. Our experience began with pulling a group together out of our initial MOREOB team whose members had become attuned to working collaboratively on issues, embracing best practice and evolved problem solving. The spread of this reform is evident among all staff now and we celebrate our success on a regular basis. Consistency and sustainability, while a challenge at times, are maintained by regular reporting to all stakeholders, including our community.”
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More than OB

We can apply a similar approach to communication and teamwork that we bring to OB to adjacent maternal/infant care departments and even other hospital units such as emergency, ICU, cardiology, and other risk management areas.