Off the Chart, San Antonio Express-News
Country/area: United States
Organisation: San Antonio Express-News
Organisation size: Big
Publication date: 3 Dec 2020
Credit: Marina Starleaf Riker, Christian McDonald, Yoli Martinez
A Texas mother’s chance of undergoing surgical interventions during childbirth can have less to do with her health – and more to do with the hospital where she gives birth. The Express-News spent a year (on and off because of the pandemic) investigating maternal health care and found that in 2019, more than two-thirds of the women who gave birth at one Texas hospital underwent a cesarean section or an episiotomy. These procedures can save the lives of mothers and babies. But when surgical interventions are performed at rates that are off the chart, experts say something is wrong.
The project’s publication spurred community activists in Laredo to call for renewed talks to establish a public hospital system in the city, where the only two hospitals that deliver babies are for-profit.
The hospital has not publicly responded to our reporting, but internal communications among staff members suggest that it is considering hiring a laborist. If that comes to fruition, we will be reporting that.
The searchable database and reporting was widely circulated among birth workers and moms’ groups on social media. We heard from several folks who were especially thankful that the searchable database was finally made public. Prior to our reporting, no such tool existed where women could search those measures for hospitals on a centralized website in both English and Spanish.
It should also be noted that Doctors Hospital of Laredo’s reduction of its episiotomy rate happened concurrently with the Express-News’ reporting process. Marina Starleaf Riker first began to inquire about its C-section and episiotomy rate in February 2020, when she began requesting to speak with medical staff and hospital quality administrators. By the time the hospital granted an interview in September 2020, the hospital said it cut its episiotomy rate in half (it would not share that data with us, which was not yet made public by the state health department).
Using hospital billing data known as the Texas Hospital Inpatient Discharge Public Use Data File, Christian McDonald analyzed numerous hospital quality measures by hospital, county and year, which included:
The Agency for Healthcare Research and Quality Inpatient Quality Indicators: IQI 33 Primary Cesarean Delivery Rate, Uncomplicated and IQI 22 Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated
The Leapfrog Group’s episiotomy rate measure, which was calculated using measure specifications from their 2020 Leapfrog Hospital Survey
Based on conversations with hospital administrators and health data scientists, McDonald also calculated total cesarean rates; the percentage of Medicaid coverage for all births, and of cesarean births; the average number of deliveries per week per doctor; hospitals’ annual number of deliveries; and the portion of births that involved cesareans or episiotomies.
The analysis was performed using R, an open source data and statistics language. You can view McDonald’s analysis and all of the documentation for his calculations by visiting https://utdata.github.io/thcic-pudf/. The source code is at https://github.com/utdata/thcic-pudf. Additionally, Riker used Excel to analyze CDC WONDER birth data by county.
To help aid our investigation and build relationships with sources, we also published an online Google Form asking mothers in South Texas to share their childbirth experiences and tell us what they wanted us to look into. More than 170 responded, and later in the year, we heard from another 100 about their postpartum experiences — a topic we’re still investigating.
What was the hardest part of this project?
The Texas Department of State Health Services does not compile rates of surgical intervention by hospital (with the exception of a few inpatient quality measures that it analyzes for hospitals in metro areas). Instead, the agency sells the Texas Hospital Inpatient Discharge Public Use Data File, which is billing data that can be used to calculate rates of procedures and diagnoses on a hospital level (it does not include hospitals, such military hospitals, that aren’t overseen by the state health department).
The four years of data used in this analysis normally would cost in-state media $8,500 and out-of-state media $17,000. That’s why the Express-News formed a partnership with McDonald, who as a faculty member at a state university was able to obtain the data for free. He wasn’t allowed to show or share the raw data with anyone but was able to share and publish aggregate figures.
It should be noted that this hospital discharge data is more expensive in Texas than in most other states. A handful of states offer similar data for free or waive fees for journalists and researchers; others charge a couple hundred dollars per year; and some, like Texas, charge thousands of dollars for a single year of data.
What can others learn from this project?
If you run into problems obtaining or purchasing data, consider partnering with individuals who can access that data. Apply for additional support through grant and fellowship programs, too. These stories were produced with support from the USC Annenberg Center for Health Journalism’s Data Fellowship. Without the fellowship’s support and guidance, our newsroom would have faced signficant difficulty producing these stories in the middle of the pandemic.
Lastly, let your audience guide your reporting. The nearly 300 Texas mothers we heard from helped informed our decision to create a searchable tool that allows mothers to look up rates of primary C-sections, episiotomies and vaginal births after cesareans at Texas hospitals. Their feedback was critical to our reporting and understanding of the complexities of patient-provider relationships.