 So, it is 9 o'clock Pacific time, so I'd love to start our quarterly webinar. This is Ariana Longley, Vice President of the Patient Safety Movement Foundation, and we are very excited to have our expert presenter, Dr. David Legrue, who's Executive Medical Director of Southern California Providence St. Joseph's Health System. So, our topic this quarter is optimizing obstetric safety and reducing unnecessary C-sections. So, looking through on the agenda, it's a one-hour webinar today, the first 10 minutes I will give an overview about the Patient Safety Movement Foundation and the actionable patient safety solutions or apps that we have created. We will then switch over for 35 minutes of a presentation that Dr. David Legrue has put together, and then we will have 15 minutes at the end for questions and answers. So, zero by 2020, that is the Patient Safety Movement Foundation's mission. We believe that one preventable patient death is truly one too many. And so, we set this goal knowing that initially we were going to be, you know, working through inside of the United States and really started spreading across the world and now are a global movement. We believe that we can achieve that goal of zero preventable deaths by 2020 by fostering new efforts and building on existing patient safety programs through commitments to zero. So, we're truly a commitment-based organization, not a membership-based organization that believes in shared learning. And so, there are a few groups who can take action with the Patient Safety Movement Foundation. We truly want these commitments to span not only state counties and states and countries, we want it to spread across the world. So, there are four groups that can take action. Hospitals and healthcare organizations can make a formal commitment around what they're doing to improve patient safety. At this time, we have over 3,500 hospitals across 43 countries who have shared these public commitments. Please take a look if you have not already on our website and see which local hospitals around you have made a commitment and what other institutions yours might be able to learn from. The second group are committed partners. And these are nonprofits, associations, professional societies, advocacy groups, and they can be part of the Patient Safety Movement Foundation connecting the dots. We know that there are so many groups out there focused on patient safety. We want to break down those silos and encourage ways for those groups to work with us. So, they sign commitment to action letters, which basically details how they will participate in the movement, sharing our mission of zero by 2020, and also, you know, joining with us in our mission. So, a few examples of those committed partners that we have are the American Society of Anesthesiology, South Carolina Hospital Association, the Emily Jerry Foundation, the Global Sepsis Alliance, just to name a few. We have over 30 of those to date and gaining more every day. The third group are healthcare technology companies. And this is, I believe, what sets us apart from a lot of the other organizations out there. Because our foundation was founded by Joe Chiani, who's also the CEO and founder of Massimo, there was a strong connection to ensuring that data is openly shared without interference or charge. And so, we encourage healthcare technology companies to sign what we call the Open Data Pledge, which encourages shared data to give clinicians a better picture of their patient, and then hopefully also allow patients to view their own data. Companies who have joined, for example, are Philips and GE, Welch, Allen, Cernar, IBM Watson, just to name a few. The fourth group are patients and family advocates. We believe strongly that patient stories can really fuel change and inspire change in health systems and across the healthcare ecosystem. We have over 50 stories of people who have either survived instances of harm or have lost a loved one preventably in the hospital. And so, you can view those on our website. We also will film a select number of those every year. And we have about 15 of those available on YouTube that anyone can use. We also offer other resources for patients and family members to have a better experience in the hospital. And earlier this year, we released a mobile app for patient use called Patient Eater. So, that's free to download from the Apple or Android Google Play Store. So, talk solutions. This is kind of our core product. They're free to download. So, please go to patientsafetymovement.org slash apps to take a look at these. But every year, since the inception of the Patient Safety Movement Foundation, we've rolled out new challenges that we believe have actionable solutions to help solve. And so, these are the full listing of all of our actionable patient safety solutions. The three and the bottom right that are highlighted are three of the new challenges that at our mid-year planning meeting we voted on as challenges that we would focus on in 2018. So, that's falls and fall prevention, nasogastric feeding and drainage tube placement and verification and person and family engagement. Today, obviously, we're going to be talking about apps number 11, optimizing obstetric safety. Again, to reiterate the Patient Safety Movement Foundation's goal, we believe that zero is the only acceptable goal. And in order to do that, we have to track how many lives are being saved through the hospitals who are participating in the patient safety movement. When we launched in 2013, we announced 60 lives saved. In 2014, we announced 600. In 2015, you can see on the screen that we announced 6,571. In 2016, that quadrupled up to 24,643. And last year, we announced 69,519. So, in order for us to really stay on track to 2020, we hope to announce in 2018 at our summit that we have been able to save 150,000 lives through the work of all of the committed groups that, all of the committed hospitals who work with us. So, with that, about the Patient Safety Movement Foundation, I would love to pass it over to Dr. David Legrue. Just to give you a little bit of background about Dr. Legrue, he's a maternal fetal medicine specialist and physician informaticist with a special interest in maternal quality improvement. After growing up in Lexington, Kentucky, where he completed his medical school and residency at the University of Kentucky, he began computer programming as an undergraduate student and earned an extra income during undergraduate and medical school. He came to Southern California to complete his maternal fetal medicine fellowship at Long Beach Memorial Medical Self-Orner Irvine. And following that fellowship, he joined the faculty at University of Louisville before returning to become the medical director at the just-opened Saddlebacks Women's Hospital in 1988, the first labor delivery and recovery unit on the west coast. And he developed techniques for providing obstetrical care via the collaborative practice model. And that hospital was a pioneer for cesarean section reduction, emergent cesarean section drills, maternal quality improvement in techniques such as controlling unnecessary inductions and episiotomies. Dr. Legrue currently is a member of the Executive Committees of the California Maternal Quality Care Collaborative, CMQCC, and California Maternal Data Center. He co-chairs the CMQCC Hemorrhage and Intended Vaginal Birth Task Force and co-edited the CMQCC Hemorrhage and Primary Cesarean Section Reduction Toolkit. He also participates on national committees, including the ACOG Revitalized Conference for Obstetrical Terms, Aim Task Force for Obstetrical Hemorrhage, and co-chaired the Aim Task Force on Primary Cesarean Reduction. In 2013, he was appointed by the Executive Committee of the Society of Maternal Fetal Medicine to chair a special task force involving the major obstetrical provider groups on the Maternal Health Information Initiative to help achieve consensus on informational needs going forward. He's worked on numerous national, natal, qualitative initiatives with focuses on c-section rates, maternal hemorrhage, elective deliveries, working with organizations like IHI, ACOG, SMFM, and CMQCC. He's the President-elect of the Pacific Coast Obstetrical and Gynecological Society, and he co-chairs the Aim Safety Bundle Task Force on increasing chances for intended vaginal deliveries and CMQCC toolkit development for the same subject. In October 2016, he accepted the position of Executive Medical Director of Women's Service for the St. Joseph Hogue Health Region of Providence Health Care, and he's been charged with developing the Individual Ministry of Clinical Institutes in Systematizing Women's Health. So with that, Dr. Lagrue, we welcome you, and thank you for your time today, and look forward to your presentation. Wow, thanks, Sherriona. So today I would like to focus on one of the obstetrical safety issues, a new look at how we can reduce cesarean section, and why this is a long-term strategy to reducing maternal mortality. I think when people look at the safety of pregnancy and the relative low numbers of mothers that actually pass away, we really sort of pat ourselves on the back, and I won't say ignore this problem, but I will say that for most people, when you initially talk about this, they think actually we're doing really well, and part of that's realistic, as I'll show you, and part of it, unfortunately, is not realistic. Today when we talk, we're really going to be focused on pregnancy-related deaths. There's a lot of different, unfortunately, a lot of different terminology that people have used over the years. Pregnancy deaths during a pregnancy are typically broken down between associated deaths that mean everything that happens within a year, and pregnancy-related, those things that are a direct complication of the pregnancy or an aggravation of an existing problem or just a chain of events are initiated by the pregnancy itself. So obviously a lot of the safety movement techniques that are listed outside of our obstetrical domain would affect associated deaths, but we're really focused on those that are related directly to pregnancy, and that's what I'll be talking about today. Now one of the aspects of why people get the idea that we're doing so well initially is this curve. If you go back to the 1900s and look well before prenatal care, antibiotics, or blood transfusion, and looked at the number of moms who passed away during pregnancy, you can see it was 800, 900 per 100,000 deliveries, meaning eight or nine percent. And really, if you look on, you know, by 1990, we had gotten this down essentially not to zero, as I'll show you, but gotten it way down from this initial number. And similarly, if you compare here in the United States to the rest of the world, we tend to think of maternal mortality as something that hits sub-Saharan Africa and South Asia and other areas where there's limited obstetrical care and facilities to take care of moms. In the developed nations, our rates are pretty low. So again, when you look at this, you think we're doing pretty good, except really when you really begin to look closer, and that's what I would like to share with you now. So what we noticed here in California, and again in the United States, is that our maternal mortality rate sort of bottomed out in the middle of the 1990s, and really approached the single digit numbers of seven, eight, nine per 100,000. But then what we noticed after the turn of the century is that this slowly began increasing. And so the sort of bottom line was we went from a single digit number to a double digit number. This, by the way, 2006, where this graph ends, is precisely where we formed the California maternal, the California CMQCC, the California maternal quality care collaborative, because we wanted to address this doubling of the maternal mortality rate. And of course, whenever you notice something bad going on, the first response people have is, wait a second, has something changed with the numbers? For example, when you look at maternal mortality, there were changes to the birth certificate that a checkbox that literally says was this patient pregnant within the last year. And of course, that increased the ascertainment, along with some changes in the ICD-10 data. But when you really drill down into it, as Dr. McDormand and co-workers did that was published last year in the in obstetrics and gynecology, you realize, wait a second, there really, even though some of this may be artifactual just from ascertainment bias, the reality is there really is an increasing trend there. And similarly, when you look and compare the United States results, as noted in the black line here, you realize the rest of the world is still lowering their maternal mortality ratio while ours is increasing. So something appears to be going on. If you graph this out in the world map, as we did a few minutes ago by looking at maternal mortality as a whole, now you get quite a different picture. You see that much of the world has improved or lessened their maternal mortality rate, as noted by the blue and the green. And unfortunately, in North America, primarily in the United States, our rates have increased. Canada's about the same. South Africa and areas down there have increased as well. So the bottom line is, is that something appears to be going on. And so when you compare us to other countries, what you begin to see is all of a sudden the United States obviously very developed nation begins to look like someone who doesn't have quite the healthcare facilities and network that we do. And this just for example, you can see that the rates are somewhere in between Chile and Mexico. And interestingly enough, some of the states, such as Texas, are actually pushing above 30, which would put it's very similar to Mexico and some very poorly developed healthcare systems. Now, let me put this in perspective, because again, I think when we talk per hundred thousand, it's very easy to say, well, gosh, that's not that many deaths in total. But let's compare the per hundred thousand rate to some notable diseases. So this graph demonstrates in the general population, the death per hundred thousand adults. And what you see of course is heart disease and cancer are the two big leaders, which I don't think surprise anybody. And those are, you know, 170 per hundred thousand, et cetera. But really, when you get up into the 30s, your your death rate during pregnancy is similar to what people die of strokes and unintentional injuries and chronic lower respiratory diseases, COPD, et cetera. So and far exceed diseases like diabetes and kidney disease and suicide. So I think when we look at it and look at our population of pregnant women to tell them they have the same risk of dying as these major diseases, I think it really puts in perspective the problem that we have. And it's really just the tip of the iceberg. The other thing is for every mother that dies, you have a lot of bad things that happen at folks. This study out in New York City, where they analyze their maternal deaths and things that nature found that for every maternal death, there were 362 severe maternal morbidity events, things like getting admitted to the ICU, having severe respiratory distress, requiring a transfusion. And so the things that we're seeing with the rise in maternal mortality also suggests that maternal morbidity, severe maternal morbidity is going up. And this data from the CDC points that out, where you can see almost a four to five fold increased risk of blood transfusion from the 90s to up to 2014. And other in it and while that it's it's harder to see on the graph because of the relative size, other things such as acute renal failure or severe respiratory distress, etc. These things that are demonstrated in the green line are also show us several fold increased risk. So what's causing this rise? What's different now than what we saw in the mid 1990s? What are we doing different? Or is it something from a demographic from patient standpoint? Well, to answer that question, first you have to go back and ask why do people die in pregnancy related deaths? Well, here's the list by Dr. Berg that was published now over a decade ago, but similar analyses and I'll share with you some of our California data in a bit, but sort of back this up and you see things like cardiomyopathy or cardiovascular disease, hemorrhage, hypertension, emboli and infection. And in some degree of order, those are the culprits that go on. So why if these are the things that women die of, why are we seeing these in increased frequency? Well, it turns out if you ask most experts what's different about women that we care for today, what are we seeing in risk factors? Well, we know mothers are older. The women over 35 and specifically women over 40 having babies is the fastest growing groups of patients that we see. And similarly, we see more maternal obesity. And so it's not unusual for hospitals and delivery units to see moms that have BMI's over 35, 40 and in some cases over 50. So clearly these mothers are at more risk and have less reserve than others. But the other big three item is the number of current C-sections and prior C-sections that we see. And this increasing exponential rate, our cesarean section rate has gone up from low single digits in the 1970s to today where the United States average is over 30. And when we say number of C-sections we see more importantly in a similar fashion, we see more prior cesarean sections. And I'll explain why that's a big deal in a bit. Now, if you analyze cesarean section, you don't want to forget that it can be life saving. And if you look at, this is an interesting study that was published in JAMA a few years ago, which pointed out if you look in the underdeveloped areas where cesarean section is not readily available, clearly maternal mortality ratios are higher. So if you go, for example, as if you remember in the graph, the sub-saharan Africa, what you see is very high rates of maternal mortality and clearly by not having timely and safe cesarean section, that's an issue. But what these researchers also found when they plotted out all these points on the graph are different countries and their cesarean section rate plotted out. What you begin to notice is, and what the conclusion of the study was, once you had a cesarean section rate over 19%, you didn't see any benefit to the mother and similar studies have been done to babies as well. You just don't see an improved outcome. And in some studies, you actually see, again, if you drill down to that flat part of the curve, you begin to see an increase in maternal morbidity and mortality. So if we look at that and put all this together, while we think cesarean is a safe thing, and I think in most mothers' minds and in most obstetricians and midwives, it's thought to be fairly safe in a modern setting. Is that real? And I stole this cartoon from the internet and I love the guy standing on the, all this stuff piled up to put his safety sign up on the wall. But I think it points out some things. So first of all, are they correlated? So what I did is side by side, here's, and again, these are not precise year ranges, but I think you get the idea. We know in the United States, the highest cesarean section rate, and this trend continues, is in the southeastern part of the country and east coast versus the further north and the further west you get, it tends to go down. And looking on the graph on the right, from the preeclampsia foundation, they found the maternal mortality rates are in a similar pattern. Now, obviously, if you're down state by state, there's a bit of variance and you'd expect that in these type numbers, but you begin to see a general trend when you look at it on a geographical basis. And when states drill down, as we did here in California, when our mortality review committee analyzed it, you begin to see that there is this correlation between mother's dying and delivering via cesarean section. Now, did the cesarean section, it caused the death directly, or was it something the cesarean section was done for? And that's the great debate, but the reality is there is a strong correlation, again, that gives us an idea. When you look at what complications happen to women that have cesarean section versus vaginal delivery, it's a pretty straightforward list. Common complications include things like infection, bleeding, wound dehiscence and breakdown, bladder infections, bowel problems, things of that nature. And if you look at the unusual things in higher incidence, you see things like hysterectomy and embolism and bowel damage and other things that, frankly, are pretty serious when they happen. But what it turns out is if you compare a cesarean first time to a vaginal delivery first time, the incidence or the difference of these things is not really quite that different. However, what we realize is when you have one C-section, you're likely to have another. What we know is in the United States that if you have that first C-section, there's a 90% chance or greater that you will have C-sections in your subsequent delivery. So that when we do that first C-section, we should not be just comparing what's the risk of the surgery today versus the vaginal delivery today. It's what's the compounded risk? What is going to happen in subsequent pregnancies and piling on? And I think that's sort of been the aha moment for us. When we compare the two outcomes, we have to compare what we're doing to that woman's health down the line. And I think as we begin to weigh that in, then it becomes pretty clear that C-section is not such a safe choice for the mom's lifetime risk. Now, the data that supports this is not new. This study that was actually European data noted that if you looked at moms during their second pregnancy and compared mothers who had had a C-section the first delivery versus vaginal delivery, you can see that the relative risk of some pretty bad things is definitely higher for cesarean sections. So things, for example, uterine rupture obviously is the obvious one at 42 times the risk, but thromboembolism, which obviously can be life threatening, is almost three times more common and things like hysterectomy six times more common. And other data has supported this. These numbers come from a study that Anna Gallean and I did out of the Saddleback data. And again, we compared relative risk of some pretty substantial things like placenta previa and suspected rupture and things. And just as the European data had shown, we could show that there was a definite several fold increase risk in things of that nature. What's the main factor in that? Well, it turns out probably the biggest thing you can point to with all of this is abnormal placentation. Because the uterine scar is in the lower segment, you tend to see placenta previa where the placenta is overlying the cervix more frequently. And you also see what we call placenta acreta. Normally, as shown in the diagram in the middle there, normally there is a layer of tissue that we call the decidua that lines the uterus between the placenta or after birth and the uterine wall. So that when you go to do a delivery, the placenta after the baby is delivered will just peel off the wall of the uterus. Unfortunately, because of the scarring in early placental development in the uterine wall, what we see on an increased percentage of patients who had had C-section and I might add this is true of any uterine surgery where the the lining has been disrupted, you lose that layer in a certain percentage of patients. So when you go to deliver that patient, you cannot remove that placenta easily. And there's actually higher degrees of that all the way up to what we call for creaida, where the placenta actually grows completely through the wall of the uterus and into structures like the bladder or the big blood vessels that are adjacent to the uterus. So you can imagine this presents the surgeon with quite the challenge. And today we actually have medical centers that call themselves a creaida center that specialize and focus on these things. Now the net result is the only way you can deliver this patient and stop the bleeding in many many cases is to remove the uterus. And what studies have shown is you're seeing an increasing rise in these creedas and a subsequent increased rise in hysterectomy, cesarean hysterectomy where we're having to remove the uterus. These data that were published by Dr. Lewadol show the 20 year rise in placenta creaida. And and other evidence that I'll share with you shows that this continues, this rise is continuing past. Now why is that so has that been documented that number of c-sections correlate to all of this stuff? Absolutely. This study by Steve Clark was published in 1985. A subsequent study by Dr. Silver and the and the researchers in the maternal field network some 20 years later would essentially confirm Clark's data was from USC in a single institution. Silver's study would subsequently confirm that in multiple institutions and you can see this exponential rise in placenta previa based on the number of c-sections so that by the time you got to four and above you're talking over 10 percent of patients, one in 10 patients will have a placenta previa and of those patients if there's a previa 70, almost 70 percent of them will have a acreta and so when you begin to get up there again this exponential rise in risk what you begin to see is these become extremely extremely risky patients. Now other other parts of the world are noticing the same thing. Here's this Higgins data from the European Journal of Obstetrics and Gynecology also noted that the frequency of acreta is steadily rising with the c-section rate and then it began to double as you saw patients with previous c-section scars and again you know pointing out this correlation between that. Van and Aker and all also showed this and showed the worldwide review of peripartum hysterectomies and showed obviously placental pathology made up a huge percentage of that is 38 percent, uterine rupture made up 26 percent so if you combine it about two-thirds or so of hysterectomies were being done for something that primarily relates to having a prior cesarean sections and you can see that boiled out in his odds ratio where if you were having a c-section the odds ratio of needing a cesarean hysterectomy was 11 times and if you'd had a previous c-section it was seven and a half times and these are not benign things. The average blood loss was 3.7 liters and for those obviously not it's not a number obviously I would expect a lot of folks to know the total blood volume of a maternal of a mom at term is about is about five or six liters so over half of the mom's blood volume gets lost during the average procedure and and of course some of these it's it's much more than that now what was the mortality the mortality that that those workers found overall was that about five out of a hundred mothers who had to have a hysterectomy passed away now obviously that was worse in poorer settings where it was almost 12 per 100 versus in richer settings such as the developed Europe and North America two and a half per hundred but even in those settings this became a life-threatening situation and again not only is it mom's dying you see some really horrible things and these data again it from the CDC acute renal failure 369 percent increase blood transfusion 363 percent adult respiratory distress syndrome 100 again just to back up what we're seeing in in these patients of this massive massive increased risk and I always love this comment from Dr. Chandler I wish I had said he's a surgeon and he said you know medicine used to be simple ineffective and relatively safe now it's complex effective and potentially dangerous so what it reminds us is is that when we do a life-saving procedure like cesarean section we have to realize that that our actions could potentially be dangerous now can we do anything about it it's obviously the question well the simple answer is yes first of all if you look at cesarean section rates and this is our data from california from 251 hospitals and what you see is the rate the range of c-sections is 15.6 the up to 75 percent now obviously some of those with very high or low numbers and maybe that's skewing it but you see this wide range of differences between hospital hospital and while people always say but wait a second my hospital only takes care of high-risk patients the truth of the matter is when you really analyze the data it's that's not the case now when we in quality improvement see such variation that's actually good news because what it means is we can improve it there are things that folks are doing on the left side of this curve that the people on the right side of this curve could be doing and lower their cesarean section right and that's why we put together both at the national level the the safety bundle that had a list of things that we can do and we'll be putting putting many of these in in our apps there also has been a very detailed we had a project where we put together a very detailed toolkit that we're now implementing in california has been widely downloaded in many parts of the world that people are using and as we run our collaboratives as we get hospitals to do these things we're always learning and improving and so there's a lot of things where you can see again that hospitals can lower their c-section rates so we're seeing a lot of success in many of our hospitals so what's the conclusion well first of all i want to remind everybody this is an international problem and unfortunately we go back to that uh hysterectomy data uh not only is it an international problem that everybody's increasing their c-section rate it's one thing to do it in north america and europe it's another to do it in in countries where they don't have the support so maternal mortality is going to be even worse uh from this because they simply don't have the infrastructure to deal with these patients so we have to keep that in mind so again this rising maternal mortality is a worldwide issue um unfortunately c-section and its compounded long-term risk is probably contributing to this and therefore the long-term reduction of maternal mortality and will require that we work together to reduce unnecessary cesarean sections efforts have started and people are working on it but we need new research we need new strategies and we need new technologies to help us with this because again this is a serious problem that's going to require a serious answer so i know harriana was very worried about me leaving time for questions but i think i did so uh harriana i'll turn it back over you to to to lead that or help organize of course thank you you were so concise you actually ended four minutes early so i appreciate um your attention to the time um so yes we have the next um i guess 19 minutes for questions um and first i just i want to thank you so much dr legru for for giving such a great overview and um giving us kind of an international perspective as well so thank you again it was a brilliant presentation um did you have a question um this is remanashivi the director of development at the foundation um i was it's funny but i was going to just uh put posting on facebook regarding this issue and the fact that we have a very high rate in california and i was wondering whether we can use some of these slides because i need to show that it's on the rise that mostly to make it simple it has to do with the rise of c-section among other things and that yes we could do something about it so can we uh how can we absolutely obviously i'll leave it up to you with some of the legal stuff about what you can post and not post but yeah i mean most of what that shared with you i think is is published literature and and you know as i think arianna right with in the patient safety movement we're all about sharing stuff so absolutely feel free on on my part to to do this and i think one of the critical factors going forward to to facing maternal mortality i don't want to scare women that are pregnant um i you know i mean that's never a good thing but i do think that that women need to be informed about this and i one of the problems is that i said earlier is that um patients unfortunately if if you just ask somebody off the street hey isn't it safer to have a c-section than a vaginal delivery first of all they're they're mostly thinking about their baby and again that's a lecture in itself but there is some downside risk and now you know um but i think as far as their well being they don't appreciate the compounded risk and there's been some wonderful work by the creta foundation and other people in the area that are trying to get this message across about the compounded you know subsequent risk to people down the way but uh unfortunately it's just not out there in the public yet yeah and then just to close the loop on that so the presentation itself as well as the audio recording um of this webinar are posted for all of our quarterly webinars on our website so they can be accessed by anyone after and i will make sure to share the link with people who may not have been able to join today um but dr legrew i did have a question so that that was you know i was wondering if you had any strategies kind of deb tailing off of what rima asked and what you had how you had responded was you know how do you position this to you know consumers of health care to women to their families without scaring them um it's you know obviously a you have hormonal women who are very you know want to make sure that they're taking care of themselves and their babies but you know how do you position that are their tools that are accessible um that hospitals use to help with those conversations yeah i i think it starts with with patient education and putting it in a realistic pose um i think one good news about all this stuff is in a you know again i've painted a pretty scary picture understand that but if if we know it's coming and we prepare for it there's a huge you know these are things that you do see better outcomes and and some as you know some of our work on hemorrhage and and other uh uh of the safety measures point out if we're prepared and we're ready and have the right people there to take care of it we can mitigate a lot of this uh morbidity as well as mortality so i think being prepared and that's why it's important to let people know but again i think that you know it is it's a very um and i can tell you this from experience in in my career where where i had to deal with a lot of these type types of conversations with patients very found line between scaring somebody into something or out of something and uh educating them on the real risk and benefits and i think we as providers i know we we tried to work some of this into the toolkit to give people better ways to educate and and not you know and fairly let there be shared decision making without over overdoing it so to speak but again i would say that unfortunately in this issue that the the knowledge deficit is really more about people don't understand that there are these downside risks may i ask you something we need to get to the root cause of the problem in a situation in i mean in any situation so what has been done with the OBGYN and the physicians who basically say let's do a c-section and that's why we have c-sections on the rise and this is this question is from a lay person who knows nothing about this still i came across this indicator on the website on our website i'm like oh my god in california it's higher than i thought it is so what is being done with the physicians who are saying you need a c-section and i hate to get the insurance companies involved do we need also to educate them that hey if somebody's describing that c-section you need to let your member think twice about this yeah well the the short answer is there's no short answer but um the the realistic answer is there are obviously clinical things we can do um a lot of what we do in the toolkit and what we do in the apps is sort of sort of trying to get people to do what we call shorter easier and more effective and therefore more safe delivery techniques things like not admitting people who are not in labor things like doing better jobs of ripening the cervix before labor so that we don't end up with these 36 hour labors that end up requiring a c-section so there's clinical things we can do but again there's a lot outside of uh what we can as clinicians control and i would get into payment reform i do know that uh there there are strong discussions going on amongst all the payers about not rewarding uh c-section so to speak which is hard to do because it's not just about the dollars as you mentioned it's you know i can spend as a doctor uh you know 45 minutes in the operating room or i can you know go through this uh yet you know 12 18 hour labor with the patient and and things of that nature and so it's not just that so there are some practice changes and some other things and then and then i would say there's things like a tort reform um yeah unfortunately the there's a paper it's very old but it's probably still true where you're 10 times more likely to get sued for not having done a c-section than you are of doing one and as long as that's the perception by doctors it obviously pushes them uh towards that so again i think there's a a zillion things and uh that's why the toolkit is so long but um you know the bottom line is there's lots of things we can do to help so the other question if if i need you to come and speak to various groups of women how yeah he's he's in our network okay yeah yeah ariana i'll meet you go ahead dr lucre now i was gonna say you'll make me so that's easy yeah since dr lucreux local and is our chair of the obi safety group he's available uh so i want to open up to the rest of the people who are on the line we still have about uh 10 minutes for questions does anyone have any questions make sure that you take yourself off a mute okay claire um manna from hqi has a question but she's on mute so she i think is going to type it out so we'll read it to dr lucreux hey can you hear me okay good hi everyone sorry i'm i'm struggling with the a cold and sore throat so hope but hope you can hear me thank you so much for putting this webinar on and thank you for your time dr lucreux um i wanted to ask you about the toolkit because what we find with a lot of hospitals is um the staff have read it and they are aware of it they know that it exists and there seems to be a gap between the knowledge and implementing the toolkit in their hospitals so there's there's a science to implementing any toolkit i think and what has been some of the steps that you've taken in your own experiences to to get things like the toolkit up and running your spreading the information around in in your facility because i know that some hospitals in california are struggling with that yeah great question claire because i think compared to some of the other safety toolkits and things that nature we put in um you know c-section reduction is not a overnight thing and it really takes first changing the culture and and getting you know providers to understand the importance of it as well as obviously patients and and other groups involved in all this but i think first of all we set the expectation that this is not first of all going to be something you're going to be able to do in a few months this is going to take a year two years three years to to really get firm control and then it's going to be something that people have to work with chronically we need to make we need to bake these changes in and make it uh you know a cultural thing so i think setting those expectations are important i do think that good news is oftentimes uh we can analyze why we're doing the c-sections in the first place in our institution so to speak in other words you can do either here in california if any of the hospitals as you know can can look in a maternal data center and they can get an idea of things they need to work on is it failure to progress is it inductions is it over-reading of you know fetal heart rate strips and c-section for fetal concern so you can get a direction that it's it's hey these are the things that might be most helpful and bring our rates down you know quickly and then lastly i think the big tip i that i'm telling everybody every every time i give this talk into a hospital or is transparency transparency transparency and i am a huge believer that we as caregivers have no right to hide c-section rates from anybody and i i think we have to be open about you know what we're doing and i i think you know i because just as i showed you the variation between the hospitals um you know obviously that the hospital the patient chooses can make an enormous difference in their c-section risk but then the other the other part of it is when you drill down within the hospital you see that kind of variation provider to provider so i think patients can have that conversation when they walk in for their for their first visit or perhaps they're they're getting to no visit whatever you want to call it where they where they really have that conversation with the provider what's your c-section rate is and why is it that way and again i i realize that takes some education and some sophistication but i i just think it's very hard uh we we know we have providers the the same way obviously has showed you the hospitals that you know it's your first pregnancy you have a you know you have a 75 chance of getting a c-section versus we have providers where it's you know uh 10 15 percent so so i think i think again transparency is a huge deal too yeah yeah we're we're huge advocates of that too and the um n-t-s-v c-section rate the p-zotomy breastfeeding and v-back rates will be published uh next year in january so those will be public again so thank you appreciate it cool thank you give better thank you great any other questions out there we still have about four minutes this is claire again yeah i will ask another question if no one else is sure um i read somewhere or heard it on npr about um uh in north carolina there is a huge disparity between uh deaths among african-american and and Caucasian women and they were able to close the maternal death rate they were able to close that gap between that disparity by implementing i believe it was like a pregnancy medical home and it was geared for Medicaid patients do you think are you familiar with that model and is that something you know i have read a bit on that but but i don't want to claim expertise on that i i think the the more general point is yes i i ain't uh you know as you know we have the same disparity here in california and you know throughout the country and my suspicion is throughout the world and how we care for those patients and how closely we watch them i think it's interesting i think if a 45-year-old woman comes in anybody's office they're aware that that woman's at an increased risk and they're going to you know check and double check and and make sure uh that you know they know a 45-year-old woman having a baby compared to a 25-year-old woman it is is different on the other hand i think we need to do the same thing in uh classifying in whether it's race or you know obviously socioeconomic factors that are increased risk and i i just think we need to again i obviously be careful not to to separate out care for patients and because everybody deserves good care but clearly there are populations like you say of folks that that need special attention. Thank you. Dr. Legru, thank you again so much for your leadership and leading us through this super important issue for those of you who are still on the phone or are listening to us later as the recording. We will have a reducing unnecessary c-sections panel at our upcoming world patient safety science and technology summit February 23rd through the 25th in London. Dr. David Legru is moderating that panel and we're really excited to have that as one of our focuses so keep checking our website and feel free to participate in and come along with us to London so thanks again everyone and we will update you on our agenda for quarterly webinars in early 2018 with which topics we'll be focusing on next year. Thank you so much. Thank you. Take care. Bye. Bye.