EBB 403 – Why Is My Hospital’s Cesarean Rate So High (or Low)? with Dr. Emily White VanGompel, Family Medicine Physician and Research Scientist

Dr. Rebecca Dekker – 00:00:00:
Hi, everyone. On today’s podcast, we’re going to talk with Dr. Emily White VanGompel about how culture on a labor and delivery unit can influence the Cesarean rate. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. Today, I’m so excited to welcome Dr. Emily White VanGompel to the Evidence Based Birth® Podcast. Dr. White VanGompel is a family physician by training and an anthropologist at heart. Her work focuses on improving the quality, safety, and human-centeredness of perinatal healthcare by examining organizational culture. She completed a research fellowship in quality, safety, and comparative effectiveness research training at the University of California, Davis, and a certification in dissemination and implementation science from the University of California, San Francisco. Dr. White VanGompel joined the University of Illinois Chicago’s Department of Family and Community Medicine in 2023, where she has been continuing her work as principal investigator on the AHRQ-funded grant supporting vaginal birth in Illinois, the role of eunuch culture. Throughout her research career, Dr. White VanGompel has worked closely with perinatal quality collaboratives throughout the country, implementing the Labor Culture Survey as a tool for hospital quality improvement and research. Dr. White VanGompel’s work has been published in major academic journals and featured in the New York Times and Business Insider. Dr. White VanGompel, welcome to the Evidence Based Birth® Podcast.

Dr. Emily White VanGompel – 00:01:56:
Thank you. I’m excited to talk with you all.

Dr. Rebecca Dekker – 00:01:58:
Yeah, and we were so excited that we were connected to you by Dr. Morgan Richardson Cayama, who’s been a team member here at EBB. And she said, you all have got to talk with this researcher I know. So, can you tell us your story about what got you interested in studying the culture of labor and delivery rooms?

Dr. Emily White VanGompel – 00:02:18:
Yeah, sure. So there’s this in anthropology, there’s this idea of being of the culture or being outside of the culture and looking in. I have the advantage of being a little bit of both in this area. And it really started when I was a kid. I’m a middle child of five siblings, and my mom had her first two babies in the hospital and then decided because of her experiences in the hospital that she wanted to try home births. And so she had her next three babies at home. She had a midwife with me, and then she had a family physician that worked with a group of midwives for the other two. And we were pretty spread apart families. So by the time my youngest sister was in gestation, when my mom was pregnant with my youngest sister, I was already 10, 11 years old. So I was pretty aware of everything and what was going on. And there’s a lot of preparation and education. That was required by that practice. If you were planning home birth, they also delivered in the hospital. So they ran, you know, the spectrum. And I went with to all of the educational sessions. So I watched all the videos with my parents. Like I learned, you know, what to do if things, you know, weren’t going well and you needed to go to the hospital or, you know, how to support things that were going to be needed during the labor and things like that. And that was really fascinating, you know, to me then. But it was also sort of the sense that this is a rite of passage for the whole family. This is a deeply personal journey that changes the way the family looks, you know, and is from then on. So it was very much an empowering experience. It was meant to be very focused on that person giving birth. So that was my culture going forward. I didn’t necessarily think, oh, I’m going to go do birth. But I knew from a young age I wanted to be a doctor. I went to undergrad, got really obsessed with medical anthropology. And are you familiar with And the Band Played On, that movie or book, either way?

Dr. Rebecca Dekker – 00:04:15:
I am not. No.

Dr. Emily White VanGompel – 00:04:16:
You’re not. Well, for public health geeks, I highly recommend it. So it’s a story of the very first, the public health response to the very first few years of the AIDS epidemic in the U.S. And, you know, details kind of like all of the mistakes that we made. But there’s this tension between, you know, culture and people and humans versus what we need to do to stop the epidemic. And it was really just impactful for me because there’s like so many scenes in that. I prefer the movie. I know the book is good, too, but I prefer the movie. They had this, you know, these these town hall meetings in San Francisco about should they close down the bathhouses or not? And you have this very sort of like young and in the movie, at least handsome public health official who’s trying to explain, well, here’s why we need to do it. Because the AIDS, AIDS is spreading. We don’t know exactly why, but we’ve we’ve connected it back to the these bathhouses. And of course, the public response is just horrified at this. Right. And angry and furious like this is their safe place that’s about to be taken from them. And I think for me, what stuck with me is just the shock and the inability to understand this reaction from that public health official. That tension between the science and then the humanity and how do we reconcile those and make them both work for health has always kind of been this fascinating aspect to me. And then I went to medical school and I did my rotations trying to figure out what kind of doctor I was going to be. I came off my internal medicine rotation and then immediately went to my my labor and delivery rotation. And the internal medicine rotation was very, very pounding into our heads, evidence based medicine. Like if you were going to make a medical recommendation, you better have the evidence and know the citation, know the best study that was most recently done to say this is how we should treat this issue. And I was a little bit dismayed when I went to labor and delivery. You know, this was many, many years ago, but it’s still, I think, true in many cases that a lot of what I was seeing on labor and delivery just wasn’t. Backed up by the exact book that I was being told to memorize for my shelf exam, right? So, there was a whole paragraph in the textbook that said, electronic fetal monitoring has been associated with increased Cesarean births. It has never shown a reduction in maternal or neonatal adverse outcomes. And that was going to be a question on the shelf exam that I had to memorize. And yet I was then reporting to Labor and Delivery every day where we were monitoring everybody with continuous electronic fetal monitoring, no matter what their risk was. That was fascinating to me, I think. A lot of people get angry about it or, you know, are like, oh, they’re wrong. It’s like, well, no, there’s a reason that this is going on. What is that reason? How do we figure out how to make it better? And then there’s the issue of sort of this difference between what I’d grown up understanding birth to be and to mean and what I saw patients going through. So I didn’t see that sort of empowerment, focus on personal journey, focus on how do we support this individual who is giving birth. It was more like they were coming in to sort of be saved. If that’s the right word, and we’re going to protect you from the disaster that’s about to happen. And that just did not resonate with how I wanted to practice medicine. So I think what I decided to do after that was a bit of a rebellion against my parents, right? I was like, well. We can do this just as well in the hospital. We just have to fix a lot of stuff. And most people will deliver in a hospital. It’s safe for most people to do that, right? There are good reasons that some people really need to be in the hospital. And why shouldn’t we be able to give them the same type of experience that we can, you know, give to people from what I saw growing up? So that’s kind of why I decided to focus on this. And then I went to fellowship and I was like, well, I don’t know what I’m going to study, yada, yada. But I’m really interested in this birth issue because when I’m on the service with my family medicine people, I see birth being handled and talked about differently than when I’m on the obstetric unit. And yet I also see it spoken about differently and handled differently when I’m with my midwives. So does that actually correspond to different outcomes for mom and baby? Does that matter? And that’s what I really wanted to study to figure out, how do we figure out what, what, why are these differences in place and what matters to maximize outcomes for moms and babies?

Dr. Rebecca Dekker – 00:09:05:
What an amazing journey from being born at home, going all the way to medical school, having these realizations, and then ending up where you are today, studying the culture of labor and delivery units and how it can improve. Is there anything you want to share with us about just the impact that the family medicine aspect had on your training and practice? Because I know a lot of people think they have a choice between a midwife and an obstetrician, but there’s this other category of family physicians who deliver babies, or I should say catch babies. What tends to be kind of an overarching philosophy of that family medicine path into helping people in childbirth?

Dr. Emily White VanGompel – 00:09:48:
That’s a great question. And I would say overarching philosophy is a very big ask, a very disparate specialty. Those of us who are involved in birth, I think, are very passionate advocates for understanding how birth is part of the life course, right? It’s not a moment that, that has no relationship to your health and wellness before and after. Like, it’s fully integral. The person who’s giving birth, the parent who chooses to parent their child, they are a unit, right? And so the health of one impacts the health of the other. And I love that aspect of family medicine. I love the fact that postpartum, I don’t just get to see mom, but I get to see baby. And I mean, half of, you know, the mental health crises that happen after birth have to do with, I’m so anxious because I’m not sleeping. My baby’s not eating. My baby’s, you know, not gaining weight the way they’re supposed to. I have to go to the hospital for these hyperbillie checks. Like so much of mom’s mental health and wellness is so determined by what’s going on with baby that when I get to see both and help, you know, treat both, it just, it just makes so much more sense. That’s the family medicine sort of aspect that we bring to it. We’re looking at it from womb to grave, right? So I will do your well child checks, see that child all the way from when it’s born all the way until perhaps it’s planning a family of its own to when it’s 75 and has, you know, all sorts of chronic diseases that I get to manage potentially. So that’s a, it’s a different perspective. And I think that there’s so much in primary care that we’re expected to do. I certainly understand that it’s not something all family physicians can and should do, but the ones that are involved in birth are very passionate about that aspect of it.

Dr. Rebecca Dekker – 00:11:43:
Yeah, so you kind of have a slightly different perspective because you’re looking at it from the whole family perspective.

Dr. Emily White VanGompel – 00:11:49:
Yeah.

Dr. Rebecca Dekker – 00:11:49:
Exactly.

Dr. Emily White VanGompel – 00:11:50:
And I mean, like when I think about Cesarean birth, like one thing that I… There are a few cases that I remember where patients will come to me, you know, a decade or two after they’ve had their final baby. And, you know, I remember I had a couple of patients where we were dealing with opioid addiction. But the opioid addiction had started because they were in so much pain from the scarring from their third Cesarean. Seen in isolation, what I was dealing with is how do we- You know, treat the opioid addiction versus, thinking longitudinally, could we have prevented this individual from needing a third Cesarean on an already, you know, scarred abdomen? So anyways, that also motivates what I study as well.

Dr. Rebecca Dekker – 00:12:40:
So, also the holistic or whole health perspective as well is important.

Dr. Emily White VanGompel – 00:12:44:
Exactly.

Dr. Rebecca Dekker – 00:12:46:
So moving on towards talking about Cesarean rates, like your research focuses on something called NTSV Cesarean rates. So for our listeners who don’t know what that means, can you explain what that acronym means and why it’s important to track Cesarean rates in that group?

Dr. Emily White VanGompel – 00:13:02:
Yeah, yeah. So NTSV, so it’s nulliparous, meaning that you have not birthed before. Term, you’re at full term. So this is, you’re not preterm, you’re not at risk of having a preemie, I guess would be the lay way to say it. And then singleton, you have one baby, so not twins or other kinds of multiples. And then vertex, which means your baby is head down in the best position to come out, essentially, not breach. And the reason we talk about NTSV Cesarean rates as a quality measure is because it helps us isolate a group of people that at the start of their labor, ideally should have the lowest risk of needing a Cesarean. So this doesn’t mean that number is zero, right? There are always going to be a few people that have other indications. For Cesarean, right? Like, an active herpes infection, right? That is still going to fall into the NTSV category, but that person may be advised to have a Cesarean before labor starts. Those people that have absolute medical indications to have Cesareans that fall into the NTSV group make up a very small percentage of that group. So like less than 10%. I feel like it actually might even be less than 5 percent. It’s been a long time since I’ve looked at those numbers. The vast majority of people that are nulliparous term singleton and vertex will not have a medical indication for Cesarean before labor starts. Is that makes sense?

Dr. Rebecca Dekker – 00:14:45:
And so most of them would be able to give birth vaginally, but there is a minority that would need a medically indicated Cesarean.

Dr. Emily White VanGompel – 00:14:54:
Exactly. And then of those that start labor in that NTSV group, some of them will have an indication for Cesarean that arises during labor. But the issue with that is that. There’s a lot of decision making and a lot of different variables that go into. That need to have a Cesarean or not during labor that can be affected by, you know, culture, training, hospital situation, etc. And so that’s why when we’re looking at reducing Cesarean overuse, we use this group to sort of level the playing field to make sure that we’re not comparing a hospital or provider that only sees high-risk patients, right, that has more preterm labors. Or that has more twins and triplets that they’re caring for. We’re not comparing that person to a person that only does low-risk singleton births. So it’s trying to level the playing field and really compare apples to apples.

Dr. Rebecca Dekker – 00:15:56:
Okay, so that’s a common metric you’re looking at when you’re looking at quality of care in hospitals.

Dr. Emily White VanGompel – 00:16:02:
Yes. And we use it in research, but they also use it, you know, for the Joint Commission, all sorts of different quality metrics that are collected on a labor and delivery unit. Or at a hospital, this is a very common metric that is used.

Dr. Rebecca Dekker – 00:16:19:
You mentioned a little bit about how the decision-making process can be impacted by a lot of factors. Like, so if you’re deciding during labor if someone needs a Cesarean or not, what is unit culture have to do with that? And kind of how would you define unit culture to begin with?

Dr. Emily White VanGompel – 00:16:37:
So unit culture is this collection of attitudes, beliefs, values, and sort of norms, things that we think of as this is how we get things done on a unit. And some of these are the things that are very clearly written and put out for the public to see, right? Our mission statement, certain protocols, certain policies, and those are created usually by organizational leaders. But the sort of more, I think, impactful way of that culture works is usually below the surface in the less visible realm. And that is sort of, you know, all of the values, the beliefs, the attitudes that the people that make up the unit hold and then how they interact to reinforce certain norms. So… For instance, like if we’re thinking about, you know, certain situations where we don’t have enough nurses today. So we need to think about how we’re going to handle the different laborers and their needs. How are we going to handle that? Are we going to, you know, really try and move somebody along faster? Are we going to try and actually slow everybody down so that they’re not all active at the same time? All of these decisions that go into it, for instance, like how you handle a patient who is having. What we call a category two tracing, which is where that electronic fetal heart rate monitor is showing occasionally little clues that maybe the baby’s getting in distress. But again, the evidence in that electronic fetal monitoring is really murky. I mean, there’s a lot of false positives that we get. So do people immediately jump to, oh my gosh, that’s an indication that there might be distress. We need to jump to Cesarean because if not, we’re going to have a bad outcome. Or is that a situation where somebody will say, hey, look at this. Remember that the strongest indication is if you can do X, Y, or Z. Why don’t you go try that and then see how it looks? And you need people to do that. You need people to reinforce. How are we going to sort of enact our evidence-based medicine on this unit and reinforce that to new members also as they come in? This is how we handle the situation. This is who we go to. And this is what, you know, these different stories in our history mean, because that’s the other thing. How do we replicate expectations and norms through the stories that we tell each other, which we tell each other a lot of stories on labor and delivery, at least in my experience?

Dr. Rebecca Dekker – 00:19:23:
You mentioned like staffing, how that’s handled when you’re short staffed and electronic fetal monitoring and kind of the culture around making decisions. What about the ability to, where staff feel like they can freely speak up or not? Have you seen that influence Cesarean rates? If the nurses feel like they can’t speak up to a physician or if there’s like a strict power hierarchy where certain people have power and other people feel like they don’t have power?

Dr. Emily White VanGompel – 00:19:52:
Yes. And we’ve done, so a big part of my research in recent years has been looking at hospitals that had very high C-section rates and reduced them to low or low normal rates. And what was very striking about almost pretty much all of these hospitals that I looked at in depth was how they cultivated this. Culture of safety, which is a concept not unique to labor and delivery, but it is something that really came out of, you know, high reliability organizations, which is like aviation, where if you make a mistake. The plane goes down. So you have to operate for a long period of time with no mistakes. And you do that by having this very proactive, let’s find the near misses. Let’s talk about the near misses. Let’s come together to figure out how we can make the system better without blaming individuals, because we need to make the system fail safe, because we’re never going to make the individuals fail safe. And so that is an approach that really prioritizes psychological safety, which is what you’re talking about, where if somebody that has less power sees something, they need to feel safe to speak it up and bring it to somebody with more power. Traditionally, that’s a nurse-physician relationship, but I mean, I’ve seen hierarchical relationships play out on all different ways on labor and delivery. We also have the patient in this mix, too. And where on the hierarchy does the patient feel and their family? Because a lot of times the first person to notice something wrong is the person sitting next to the person in labor, right? And we’ve heard those stories, particularly when we’re thinking about maternal mortality and in patients that were not listened to and in family members that were not listened to, which wound up having catastrophic results. So I guess to your original question, the hospitals that had really made really amazing changes had really cultivated that safety culture where nurses and patients felt safer speaking up because they were the focus of birth sort of shifted from. We’re going to prevent disasters. And the doctor is the only person that can do that. Which is a very traditional sort of like patriarchal sort of approach to managing a labor and delivery unit. Compared to, okay, we are a team. We are here to support the laboring person to achieve a safe and emotionally and physically safe outcome. And that’s really, really important. These hospitals didn’t just talk about physical safety, which I think is traditionally what we talk about in labor and delivery. They also spoke about emotional safety. How are you talking to the patient? How are you involving them in decisions? Are you ensuring that if something is changing and it’s often changing rapidly, are you sitting down with them, slowing things down so that they understand what’s about to happen before rushing into it? Are you noticing when patients are not feeling emotionally safe? And all of these things were just amazing. Quotes that we got from, you know, doctors, nurses, midwives, sometimes quality safety officers that we spoke to at these hospitals that had really changed their Cesarean rates. I talked to one midwife who described it as being an extra midwife with some of her patients that she specifically noticed were more scared, more uncomfortable, didn’t feel comfortable speaking up. And so they just really were able to articulate this culture of focusing on making the focus of birth. Got support for the laboring patient and their family.

Dr. Rebecca Dekker – 00:23:50:
Which makes me wonder, how did they create that culture shift? So to go from that kind of patriarchal paternalistic model where one person has authority and everybody else is kind of following orders for the quote unquote, the safe birth, you know, physically safe of a baby, which I think often meant like avoidance of legal liability for certain outcomes to being a more team oriented atmosphere where the family is truly at the center. So you’ve seen hospitals actually make this shift.

Dr. Emily White VanGompel – 00:24:22:
It was hard to find, I have to say. But we… We looked in California and Florida because they’d been sort of working on the promoting vaginal birth issue longest. And I was coming to Illinois at that point in my career and we were starting that initiative in Illinois. And so I was really interested in figuring out, well, what did these successful hospitals do? And they all had slightly different stories about how they made that shift. No one was the same. But, you know, for example, one of the hospitals… They sort of brought the subculture into the mainstream. That was their story. So they had this one, they had midwives, but there were only like two of them. The nurses noticed that this one midwife would, she had all of these extra things that she used and she stored them in her locker. And these things included like a Bluetooth speaker so they could play relaxing music in her patients’ rooms. The birth ball that she used with her patients. The compresses, hot and cold compresses, massage tools, aromatherapy. All of these non-pharmacologic birth support sort of components. But she kept them in her locker, right? This was-

Dr. Rebecca Dekker – 00:25:37:
Because otherwise they’d probably walk away, right?

Dr. Emily White VanGompel – 00:25:41:
And one of the nurses really liked it. And so she started asking the midwife, can I borrow this? Can I borrow this? Can I borrow this? And was using it then with her patients. And then one of the doctors started asking for it because they saw, wow, this is a really positive thing for my patients. They feel better. I’m getting called less. It’s a win-win situation. And so the whole unit, the nurse manager said, well, we don’t need this hidden away in a locker. We’re going to bring it out and we’re going to make labor support carts. And so they created all of these labor support supplies. They’re centralized. They’re continually replenished as needed on the unit. And every single member of the staff knows how to use them. So that’s the other thing. They created ownership of this is what we provide on our unit. This is a value of our unit, which is active labor support. And so then that became the norm. And then people who come in from outside are acculturated to that norm. They also did something really great, which I love. And I don’t know. I wish this would spread to more hospitals. So I know it’s hard. They actually were creating a walking path for patients in labor. Where they could, you know, walk around the unit, but then I think it also had a little bit outside the unit and there would be stations where they could pause if a contraction was coming on, that it would give them, you know, different positions to try to help the baby move into an ideal position to come out and, or affirmations to try, breathing techniques to try, you know, all sorts of different, different things, which is, you know, really just really good active labor support. That was one hospital story. And, you know, we also heard from hospitals that had different approaches. They needed different approaches. So they needed a really charismatic leader that you know, sort of had his own sort of realization moment of sitting down next to colleagues at a conference where they were going to be talking about vaginal birth rates or Cesarean rates. He made a comment to his colleague from another state. Well, I don’t I don’t know. Ours are really good. They’re in the 40s. And for those of you listening, that is not good. And his colleagues looked at him in shock and horror like, what? Oh, my gosh. Ours are too high. And we’re in the 20s. So, you know, he had that moment of realizing just how far of an outlier they were. And so went back to his hospital and really. You know, made a lot of changes where the executive leadership of the hospital started looking at doctors’ individual rates of Cesarean, NTSV Cesareans. They made it part of the incentive package. They were, you know, really monitoring regularly, calling them out as a quality metric. He sat down individually with physicians that were struggling with their rates and said, hey, what is it that your partners are doing that you’re not doing? We need to figure out what it is and we’re going to support you until you can practice that way. So that in that case was a top down. Change. And so I think it depends on each unit and their local context what’s going to work. What we see, I think, very frequently, especially more recently, what I’ve seen in Illinois is that a lot of these initiatives Quality initiatives are very nurse driven and you can do a lot with promoting vaginal birth from a nurse perspective, right? With active labor management and really getting nurses back into rooms as opposed to, you know, monitoring strips and charting from outside the room. But there’s a point that you reach where if you don’t get buy-in from your doctors, you’re just constantly butting your head against the wall. And so that’s the point that I’m really interested in and what I’m trying to work on with my research next.

Dr. Rebecca Dekker – 00:29:36:
Know you’ve been collecting some data and doing some reviews of what are some of the factors kind of in the opposite, like you said, in these places where baby nurses want to make change, but providers aren’t as interested in these. And this movement to lower the Cesarean rate. So in hospitals where they still seem to be struggling and the NTSV Cesarean rates are high, what are some examples of attitudes or norms or behaviors from? Physician providers that kind of are contributing to the high Cesarean rates.

Dr. Emily White VanGompel – 00:30:13:
Yeah. So and again, it’s different by different place. So I hear a lot. Our our unit, our patients are too high risk to be able to achieve.

Dr. Rebecca Dekker – 00:30:25:
I hear that all the time. Yeah.

Dr. Emily White VanGompel – 00:30:27:
Exactly. And there are certainly different risk levels in hospitals. You know, some hospitals will triage their high risk patients to the usual like tertiary care center, the large academic university hospital. But what’s interesting about variation in Cesarean rates between hospitals is that that tertiary care versus, you know, community hospital factor doesn’t seem to be predictive of Cesarean rates. So, for instance, I’m in a part of Chicago where we have, I think, three or four mature labor and delivery units like literally across the street from each other. And we all have very different Cesarean rates on those units, even though we are in the exact same location. And for many intents and purposes, we’re all tertiary care centers taking care of high risk patients. And so, what is different about those units is something that’s been studied ad nauseum, right, from a economic perspective, from a clinical risk perspective. And what over and over the sort of quantitative research shows is that it’s not explainable by anything that makes sense. So it’s not explainable by risk category. It’s not explainable by whether you have a NICU or what level that NICU is. It’s not explainable by how many diagnoses your patients have when they come in. But what is different is this issue of culture. And when we started in California way back in 2016, it was they were starting their Promoting Vaginal Birth Initiative to sort of work statewide to lower Cesarean rates. I started working with them because there was this aspect of culture that everybody who works on a labor and delivery unit has felt. But there was no way to measure it. And that’s what we really wanted to do because at least in a lot of the perinatal quality world, You need to, like data is sort of king. You need to constantly measure what you’re doing before and after you make a change to see if it’s actually impacting and making a positive effect. And so if you can’t measure culture and you just tell people, fix your culture. It doesn’t make sense to them. And so that’s why we really created the Labor Culture Survey. And the things on it that we’re measuring are really individual attitudes and beliefs. So you asked, like, what might make a high unit have that higher C-section rate? We ask things like, how much do you agree with or how strongly do you agree with Cesarean birth is safer for the baby than vaginal birth? Or Cesarean birth is safer for the person giving birth than vaginal birth? There’s no right or wrong answer to that. Because it depends, right? But when forced to choose if you agree or disagree with that, you start to understand. How are people actually thinking about what they’re doing? Are they actually seeing a vaginal birth as a safer outcome? Or in fact, do they really think the Cesarean is the safer outcome? Another way we ask this is about support for best practices. So I talked to you about the evidence base, right, behind labor and delivery. But what I’m fascinated by is that, you know, evidence is constantly changing. It’s constantly coming into our awareness. But we get to decide what we believe or not. And so, for instance, I was sitting next to a colleague and we were talking about the Promoting Vaginal Birth Initiative at our hospital and how we were going to work on it. And there were studies that we were talking about we were both excited about. And I was really excited about the peanut ball trap that I had read and how using peanut balls had been associated with increased vaginal births. And this was going to be great. And we were going to do it at our hospital. He was really excited by the ARRIVE trial and how we could now induce people at 39 weeks and not only prevent adverse neonatal outcomes, but we could reduce Cesarean. And we were both going towards the same goal, right? We just were taking different pieces of evidence and looking at it very differently. So, for instance, he looked at the at the peanut ball trial and he was very skeptical. And he said, well, that’s a very small trial. Why do you believe that? And my interpretation was, well, I believe it because there’s no harm. It’s beneficial and there’s-

Dr. Rebecca Dekker – 00:35:00:
Affordable and beneficial and doesn’t seem to have any negative effects.

Dr. Emily White VanGompel – 00:35:04:
Exactly.

Dr. Rebecca Dekker – 00:35:05:
Yeah.

Dr. Emily White VanGompel – 00:35:05:
And I was very skeptical of the ARRIVE trial. And he said, well, why are you skeptical? It was a huge randomized control trial at multiple centers. This is this this type of evidence is, you know, indisputable. And and I said, well, but what about the harms like this? There is a lot of potential for harm here versus a peanut ball where there’s very little potential for harm. And so we’re we’re both coming at the issue, which is we want to reduce Cesarean births. We want to do it in the best way possible to support our patients. But we’re getting and interpreting and filtering the evidence that makes sense to our own attitudes and beliefs.

Dr. Rebecca Dekker – 00:35:44:
It’s interesting, too, that he said it would improve the neonatal outcomes because it’s my understanding from what we’ve published about the ARRIVE trial here at EBB that that was not, you know, that was their primary outcome, but it did not turn out to be fulfilled by the 39-week inductions.

Dr. Emily White VanGompel – 00:36:02:
Right. Yeah, absolutely.

Dr. Rebecca Dekker – 00:36:03:
But they still kind of assume that it will improve newborn outcomes.

Dr. Emily White VanGompel – 00:36:08:
Yes. And I think that goes back to the original reason, like 40 weeks and above, right? The older evidence that was suggesting that 40, like after 40 weeks, nothing great happens in utero is how it was told to me in residency.

Dr. Rebecca Dekker – 00:36:23:
And then they bumped it back to 39 weeks. Nothing good happens after 39 weeks. Right.

Dr. Emily White VanGompel – 00:36:28:
Exactly.

Dr. Rebecca Dekker – 00:36:29:
Yeah.

Dr. Emily White VanGompel – 00:36:30:
Yeah.

Dr. Rebecca Dekker – 00:36:30:
Which comes down to like, like you said, it’s an attitude, a belief, a cultural value. So, and I know that a lot of physicians were excited by what was a pretty, I thought. I know it’s statistically significant, but it didn’t seem to be that clinically significant, the reduction in the Cesarean rate, when there’s other things, like you mentioned, different ways of movement and positioning and childbirth and labor support that have much higher success rates at increasing the chances of vaginal birth. They’re more affordable. They don’t have side effects. But they’re not being adopted. So there are physicians leading this movement to induce everyone at 39 weeks. And the evidence isn’t really panning out to show that it lowers the Cesarean rate. So are you hearing at conferences and things like that, are people talking about that, how the ARRIVE trial has impacted Cesarean rates in their hospitals?

Dr. Emily White VanGompel – 00:37:30:
Oh, yes. We actually published a paper on this a few years back, actually. So it was like we did the labor culture survey in California before ARRIVE came out at 70 hospitals. And then we did the labor culture survey in Michigan after ARRIVE had come out and sort of been, you know, put into practice. Obviously, those are two very different states with very different populations of clinicians. But, there was a very, so there is a question on the labor culture survey about induction of labor. And we ask it in a perhaps now dated way, which is there are many evidence-based ways to reduce the Cesarean delivery rate. But how much do you agree with the following? And so, you know, it lists things like increasing midwifery care. And then one of the, you know, seven other questions. And then one of the questions is reducing inductions of labor for non-medical reasons. We saw a huge shift before and after the ARRIVE trial, but only in the physicians, not the nurses. So the nurses were still very much in favor of reducing inductions of labor with the goal of supporting vaginal birth, despite this evidence coming out. But what was interesting also about that study is that it varied based on not only whether you were a doctor or a nurse, but also your C-section rate at your hospital. And so the places that changed the most where right away the doctors were like, no, this is not a good way to reduce the C-section. We need to be inducing people. Those were hospitals that had higher C-section rates, whereas at hospitals that had lower C-section rates, there was still a dip. You know, physicians still said, well, no, I don’t agree with this as much, but it was not as large as the places.

Dr. Rebecca Dekker – 00:39:18:
So they weren’t like adopting the induce everyone at 39 weeks and they kept their Cesarean rates low.

Dr. Emily White VanGompel – 00:39:24:
Well, this is association. So-

Dr. Rebecca Dekker – 00:39:27:
Association. Okay. So this is not over time.

Dr. Emily White VanGompel – 00:39:30:
Where the Cesarean rate was lower and they didn’t quite adopt the belief. The other thing that’s really interesting, though, now we’ve replicated this twice with Michigan and now in New York, is that the write-in comments at the end of the labor culture survey by and far since the ARRIVE Trail came out, the largest, the highest number of comments I get are about induction of labor, and they’re almost all negative. From doctors and nurses. They’re almost all saying we need to stop doing inductions of labor electively at 39 weeks. And that’s from doctors and nurses at high and low C-section hospitals. This is qualitative, not quantitative. But what I can tell you is that I really feel like consequences of this, this, you know, trial that came out are a lot wider than I think anybody anticipated in terms of how it’s impacting not only patient, you know, outcomes potentially, but also just quality of work and then quality of birth, right? So nobody’s really, as far as I, the research I’ve seen, talk to patients about how they are, and I actually, maybe you guys have, and I haven’t seen it, but how they are making these decisions. But I’ve also, you know, heard from colleagues that have friends and family that are struggling with this decision. My doctor says that the safest thing to do would be to induce me at 39 weeks, but I don’t want that kind of birth. I don’t want to be in the hospital for three days and have the whole birth be under pitocin or other means of inducing labor. But if that’s what’s safest for my baby, that’s what I should pick. And it’s this really horrible sort of pressure we’re putting on patients to make that decision. Which is new. And I think an area that we really have to investigate more.

Dr. Rebecca Dekker – 00:41:22:
It’s a culture shift, which is your area of interest in research. It is a big one. I think what we see. Is that sometimes the results of the ARRIVE trial, which I took when I read the original report, to mean that it’s okay to do an elective induction at 39 weeks if that’s what the patient wants. Like, you can do it safely. But what a lot of providers took it to mean is you should induce everyone at 39 weeks. And then they kind of exaggerate the newborn results and make these broad sweeping claims about it being safer for the baby, which is not exactly what the study found. So it seems to be, like you said, it was a pivotal moment. And the epicenter was in Chicago where you’re located. And I will say that our number one place for childbirth education is the Chicago area in Illinois because people need evidence-based information because they are constantly coming up against a culture of really high intervention being done electively and kind of being pushed on people. And so they really need to arm themselves with information to kind of figure out where do I go? How do I have conversations with providers when they’re making these claims to me? So very interesting.

Dr. Emily White VanGompel – 00:42:44:
That is fascinating. But it’s, you know, and it is very much a shift that I could feel between residency and fellowship in California and coming back to Chicago and doing this work. Yeah.

Dr. Rebecca Dekker – 00:43:01:
Yeah. So you’re in the right place to be doing this research on culture and Cesarean rates. For families who are listening, like, are there any signs during prenatal care or during hospital tours or conversations with providers that can help them identify whether their chosen birth setting is more likely to support a vaginal birth if that’s what they’re wanting?

Dr. Emily White VanGompel – 00:43:25:
And I do get questions from patients about this. And the first thing I will say is that many states publicly have somewhere on the Internet C-section rates for their hospitals. It’s sometimes hard to find. So in California, they were putting it on Yelp like it was very easy to find. And in Illinois, you have to actually go to the Illinois Department of Public Health Hospital Compare website and do some manual inputting. So it’s a little bit trickier, but it is available online. You could also ask your provider, what is the hospital C-section rate? Do you know? If they don’t know, maybe that’s a sign that they’re not really invested in this issue of how do we keep our C-section rates down and keep everybody safe and healthy. So that’s the first thing. So educate yourself about what the hospital’s rate is, because even if you have the absolute best provider that you love. They, their, their rate is going to be impacted by the hospital because the nurses are going to, are determined by the hospital, the available setting, the available support that you get, whether there’s a tub, whether there’s not a tub, whether you can, you know, who you can have in the room, aromatherapy, like all that stuff that helps mitigate pain and help you cope with labor better is really determined by the hospital, not by the provider. So pick your hospital. After you’ve picked your hospital, you know, there’s, there’s different things on the hospital tour that you can kind of ask, right? So what kind of support, non-medical support do you guys offer here? How many rooms have tubs? Can I bring in my own tub? Is that something that you would allow? Do you have wireless fetal monitors? Because very few places are effectively doing the intermittent monitoring. And so most likely you’re going to need to be, you know, hooked up to a continuous fetal monitor for most of your labor. So is that a monitor that I can walk around in or is that something where I’m stuck in the bed? Because that makes a huge difference to what you can do during labor. Ask them what other support they provide. So do they have the ability to have you play music in the room, lower the lights, aromatherapy? All of that is not necessarily predictive of a C-section rate, but it’s predictive of values. Like, are they valuing supporting this process and actively supporting it? A lot of the subtler stuff, it’s harder to pick up on. So if you ask your provider, do you value vaginal birth? You’re probably not going to find that out, right? Because they’re going to say, yes, of course, that’s how we want everybody to deliver unless it’s not safe. So I don’t necessarily think that you could, you know, give the labor culture survey to your provider and figure out if they’re right for you or not. But you can ask things about what’s your opinion on non-pharmacologic support during birth? You know, what’s your opinion on movement in labor? When do you think I should come into the hospital? You know, and if the emphasis is on, well, we have to make sure everything’s okay versus we have to make sure that we’re supporting you to achieve a vaginal birth. Like, you can kind of get a sense of it, but I think it is really hard. And that’s why I think looking at the outcome of the hospital, what are they actually achieving? And then making sure that you are with a provider in a low C-section hospital that you feel like understands how to support you in labor is going to make the biggest difference.

Dr. Rebecca Dekker – 00:47:06:
Mm-hmm. As you’re mentioning places to get data, I know we tell our EBB childbirth class students about LeapFrog and show them how to use that, but not every hospital voluntarily reports their data. And I’ve also recently heard good things about US News and World Report doing hospital comparisons for different metrics. So sometimes, unfortunately, you have to do a bit of research, but I like the idea of asking your provider or maybe even asking on the hospital tour, what’s your Cesarean rate? What’s your low-risk Cesarean rate? Because if they know those rates, it’s probably a sign that at least that they’re thinking about it. Right?

Dr. Emily White VanGompel – 00:47:45:
Yeah, exactly.

Dr. Rebecca Dekker – 00:47:46:
Yeah.

Dr. Emily White VanGompel – 00:47:46:
Exactly. You can also, you know, ask your provider what their Cesarean rate is. That’s a hard one, though, too, for some providers if they’re not getting their data regularly because not all hospitals do that.

Dr. Rebecca Dekker – 00:47:56:
Or if they are maybe doing Cesareans for their colleagues, like maybe for their midwife colleagues or family medicine colleagues.

Dr. Emily White VanGompel – 00:48:05:
To be honest, like practices that have midwives that are doing managing a lot of the births. Their doctors often still have some of the lowest rates in the hospital because they’re already valuing a midwifery model of care enough to have midwife colleagues. And so they have that that approach.

Dr. Rebecca Dekker – 00:48:24:
And do you feel like hospitals that have a strong midwife culture where the midwives feel supported and there is enough of them to be able to cover birth all the time that they tend to have lower Cesarean rates or not always?

Dr. Emily White VanGompel – 00:48:39:
So I don’t have quantitative data that I can cite to you to back that up. My personal belief is that if you incorporate a midwifery model of care on your unit, then yes, it better supports vaginal birth in many different ways. And that is what we saw. So when I did my in-depth investigation of these hospitals that had changed their cultures, one of them was really amazing in California. They had a dyad model of care for every single patient that came through the door. So every patient that came through the door to labor was assigned a midwife to manage their labor and a physician to manage the medical. And so they both had their individual sort of- And those roles were very clear. And that hospital not only achieved a very significant reduction in Cesarean, but they also achieved equity in their Cesarean rates. So they were in a very high-risk part of California taking care of a very vulnerable population. And they did not see any racial disparities in their data after implementing that model of care.

Dr. Rebecca Dekker – 00:49:47:
Where everybody had access to a midwife?

Dr. Emily White VanGompel – 00:49:50:
Exactly.

Dr. Rebecca Dekker – 00:49:51:
Mm-hmm. And one more thought I had while we were talking is that some people might, sometimes I come across people who are offended when we talk about lowering Cesarean rates. So do you get that? And if so, what is your response when we’re talking about, you know, knowing the fact that there are some people who need or prefer Cesareans and that that’s a valid option, why is it important that we talk about lowering the Cesarean rate in hospitals?

Dr. Emily White VanGompel – 00:50:18:
Yes. I’m glad you asked that because it is. I think every single time I give a talk or administer the labor culture survey, I get a comment about that and that it’s so important that we make sure that we’re not making patients feel bad if they need a Cesarean. And I 100% agree with that. But at the same time, if you ask patients that have had a Cesarean, if they wanted that Cesarean, like if they elected for it. Only about 1% of them will say yes. Whereas if you ask physicians that if their patients that had Cesareans wanted those Cesareans, a lot of them will say, oh, yeah, most of, you know, I have a ton of Cesareans on request. And it’s like, well, where’s the disconnect here? And so I think there is different perceptions of how Cesarean is viewed between physicians and their patients. And so when I get that comment from physicians and clinicians, I think it’s really important to sort of bring up that evidence of, hey, well, of course, nobody should feel bad for having a Cesarean. That’s nobody’s goal. Nobody’s goal. But at the same time, you not telling your patient about the risks of Cesarean, particularly in subsequent birds, so that you don’t make them feel bad is not okay. That’s not the answer, right? The answer to not making people feel bad about needing to have a Cesarean is not to hide the truth about the true risks of that issue. So when I get that comment from clinicians, that’s how I respond because- Somehow physicians think that more people are requesting Cesareans than patients actually think. So there’s a disconnect. It’s really not the solution to make everybody feel good by pretending there’s no problem. There’s no risk involved in future pregnancies. There are other ways to make people feel empowered and realize that they have given birth and done an amazing thing if they have had a Cesarean. When I get that from patients, or rather what happens more frequently is I’ll be talking to an audience of mixed clinicians where they’re not all involved in labor and birth. And I am a family doctor, so I do talk to a lot of clinicians that have their only experience with birth is really their own or their spouse.

Dr. Rebecca Dekker – 00:52:40:
Right. So they’re thinking about their own birth when they talk.

Dr. Emily White VanGompel – 00:52:44:
And that’s a different thing than when I’m talking to a labor and delivery clinical audience because that’s coming from their own very visceral experience and wanting to feel like their Cesarean was justified and their Cesarean was medically necessary because otherwise it doesn’t feel good. And that’s actually a paper we recently wrote on individual females’ attitudes, experiences with birth, and attitudes on the Labor Culture Survey towards supporting vaginal birth. And if individuals had had, had experienced their own Cesarean. They were less likely to agree with all of the different metrics supporting vaginal birth. So they were, for instance, I mentioned those questions about overestimation of Cesarean safety. So a Cesarean birth is safer for the baby than vaginal birth. How strongly do you agree with that? Or a Cesarean birth is safer for the person giving birth than vaginal birth. How much do you agree with that? People who had had a Cesarean themselves and not had a vaginal birth were more likely to strongly endorse that Cesarean is safe. Than people who had had a vaginal birth or than people who had had both. And that was consistent throughout all of the different scales about personal fears, about assessment of best practices to reduce the Cesarean rate. But what was really fascinating that I thought, was on the culture scale, where we’re looking at what are the norms that support vaginal birth on your unit. People who had had both, where, more likely to rate the culture on their unit as less supportive of vaginal birth than the people who had had Cesareans or vaginal birth only. And we really thought about this a lot, like what could explain this finding? How are people understanding this question? And based on their own individual experiences of giving birth, what we hypothesized was that these people who had experienced both were able to sort of understand a little bit better what had supported them versus not supported them? And were a bit more critical of what was going on. And so that’s how we interpreted that. But it’s still open to a lot of interpretations. But what’s very clear is that your own individual experience with birth impacts your attitudes and beliefs and what you understand to be the right way to do birth on labor and delivery. And so, it’s a really, really difficult thing. How do you support people who’ve had an experience that is going to impact their future practice in a way that helps them continue to believe the evidence that somehow didn’t apply to them?

Dr. Rebecca Dekker – 00:55:34:
Yeah, it’s hard, but you’re right. It’s an individual issue. And for some people, it may have been traumatic or, like you mentioned at the very beginning, an integral part of their life course. And then when we’re talking about promoting vaginal birth and lowering Cesarean rates, I think you and I are talking about it more from a public health perspective, like population level. And we’re not here to judge individuals, but I can totally see how somebody would feel personally attacked by talking about lowering Cesarean rates if they truly feel that their Cesarean was necessary, or maybe they don’t feel it was, but they want to believe that it was. So it brings up a lot of emotions for a lot of people, not only for if they gave birth, but for their partners or for maybe when their mom gave birth to them, like hearing their birth story and how they were saved by a Cesarean can be life altering for some people.

Dr. Emily White VanGompel – 00:56:29:
Yeah. Yeah, it can. I mean, the other thing I also just say is we’re not going for zero. Like nobody thinks the Cesarean rate should be zero. And we’re going for a safe rate that does the right number of Cesareans to save the most lives, decrease morbidity, but not increase morbidity by doing ones that could have been avoided.

Dr. Rebecca Dekker – 00:56:51:
Mm-hmm.

Dr. Emily White VanGompel – 00:56:51:
Yeah.

Dr. Rebecca Dekker – 00:56:52:
That’s a great goal. Are there any resources you want to share with us before you go, like how to access the labor culture survey or anything else like that?

Dr. Emily White VanGompel – 00:57:01:
So the original, we have we have many publications, so I can actually send you the like top three, perhaps that would be most helpful. But the development of the labor culture survey and all of the psychometric testing that went into that is open access published in birth. I think, I guess. It’s been a while. And then we did a revision as well, incorporating more of those safety culture items. So I’ll send you both of those articles. And then perhaps the very first study that we did where we looked to see, can you predict a hospital C-section rate simply based on their culture score as measured by the labor culture survey? And we found that, yes, you could. That was done in California. So I can send you that article as well.

Dr. Rebecca Dekker – 00:57:46:
Awesome. And we will make sure to link in the show notes to a few other publications that have to do with Cesarean rates. So- Well, thank you, Dr. White VanGompel for coming on the podcast and sharing all your research and experiences with us. We really appreciate it.

Dr. Emily White VanGompel – 00:58:01:
Yeah. Thank you so much for having me.

Dr. Rebecca Dekker – 00:58:03:
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