The Today Show, not known for their excellence in birth journalism, showed a live cesarean on air earlier this week. The birth advocacy community has weighed in on the shoddy reporting and the circumstances of the cesarean, pointing out that the stated indications ('big babies run in the family' and 'she was past her due date') do not in fact justify elective primary cesarean surgery.

When I heard that the cesarean had taken place at Beth Isreal Deaconess Medical Center in Boston, I had an 'a-ha' moment: That's the place where Paul Levy is President and CEO. And he has a blog. And his blog has been a sounding board for ideas about health care reform in general and transparency and practice variation in particular. I decided to leave a comment.

Here's what I wrote about what I really think about the Red Sox the responsibility of hospital leadership to address problems in maternity care including the excess use of cesarean surgery.

I'm sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.

Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the 'normal range' ('25-30%') reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have 'Red Sox Nation plus 1' but you now also have 'NTSV cesarean rate plus one' - the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was 'big baby'.)

I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.

(BTW, Paul Batalden's [whom Levy mentioned in a recent blog post about practice variation] daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)

After another commenter suggested that perhaps the circumstances of the cesarean were a private matter, I had more to say:

I agree that this isn't an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much 'business' the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we're going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.

Just in the past week, there's been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California's maternal mortality rate. Seems like there's plenty of 'blog fodder' other than the Red Sox angle.

Levy's commitment to openness and transparency is unique in the hospital administration world and I support it wholeheartedly. I have to admit it felt like quite a thrill to leave a cogent comment on a blog of a hospital CEO. Even when I've worked for hospitals I never had that kind of access. Of course listening doesn't necessarily translate into doing. I hope that Levy recognizes that his hospital could be doing much better in their provision of maternity care to the community, begins documenting quality improvement efforts on his blog, and welcomes the input he receives from those of us who have thought quite a bit about what high-quality, high-value maternity care looks like and how to get there.

*Jill from The Unnecessarean coined this term.

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